good vibrations : management of deep brain stimulation for et and pd michael pourfar, md co-director...

Good VibrationsGood Vibrations: : Management of Management of Deep Brain Deep Brain

Stimulation for ET and PDStimulation for ET and PD

Michael Pourfar, MD

Co-Director Center for Neuromodulation

NYU Langone Medical Center

New York, NY

Deep Brain StimulationDeep Brain Stimulation

Precise placement of stimulating Precise placement of stimulating electrodes into various brain electrodes into various brain structures - (thalamus, subthalamic structures - (thalamus, subthalamic nucleus, globus pallidus)nucleus, globus pallidus)

IndicationsIndications

FDA approvedFDA approved::– Essential Tremor (Vim thal)Essential Tremor (Vim thal)– ParkinsonParkinson’’s Disease (STN, GPi, Vim)s Disease (STN, GPi, Vim)

FDA HDEFDA HDE::– Dystonia (GPi, STN)Dystonia (GPi, STN)– OCD (AlIC)OCD (AlIC)

Possible future indications:Possible future indications:– TouretteTourette’’s (CM thal, GPi)s (CM thal, GPi)– Depression (ACC )Depression (ACC )– Cluster headache (posterior hypothalamus)Cluster headache (posterior hypothalamus)– Epilepsy (medial temp, ant thal)Epilepsy (medial temp, ant thal)– Chorea (HD, neuroacanthocytosis, etc)Chorea (HD, neuroacanthocytosis, etc)

How DBS works (?)How DBS works (?)

In movement disorders, there are specific In movement disorders, there are specific altered firing patterns, increased neuronal altered firing patterns, increased neuronal synchronization and low-frequency synchronization and low-frequency rhythmic oscillation of neurons within the rhythmic oscillation of neurons within the basal ganglia and thalamus.basal ganglia and thalamus.

DBS may override the altered patterns and DBS may override the altered patterns and low-frequency oscillations by replacing it low-frequency oscillations by replacing it with tonic high-frequency output.with tonic high-frequency output.

How DBS really works…How DBS really works…

Regardless of how DBS theoretically Regardless of how DBS theoretically works, it only ACTUALLY works when a works, it only ACTUALLY works when a well positioned lead in a well selected well positioned lead in a well selected patient is well programmed!patient is well programmed!

A great DBS surgeon who doesnA great DBS surgeon who doesn’’t t program effectively or a proficient program effectively or a proficient programmer working with misplaced leads programmer working with misplaced leads will result in an unhappy patient!will result in an unhappy patient!

Goals of DBS Goals of DBS ProgrammingProgramming

Suppress/improve symptomsSuppress/improve symptoms

Minimize adverse effectsMinimize adverse effects

Reduce battery drainReduce battery drain

Programming BasicsProgramming Basics

Know your target and what it treatsKnow your target and what it treatsSelect contact with the best efficacy and Select contact with the best efficacy and largest therapeutic windowlargest therapeutic windowDecide whether monopolar or bipolar Decide whether monopolar or bipolar preferable based on efficacy/tolerabilitypreferable based on efficacy/tolerabilitySelect voltage that suppresses symptoms Select voltage that suppresses symptoms maximally without inducing SEsmaximally without inducing SEsSelect pulse width & frequency similarly, Select pulse width & frequency similarly, changing one variable at a timechanging one variable at a time

Stimulation ParametersStimulation Parameters

Rate(Hertz)

number of pulses per second

Pulse Width(sec)

duration of each stimulus

Amplitude(Volts)

intensity of stimulation

DBS Lead Electrode Selection DBS Lead Electrode Selection

* The negative electrode exerts the therapeutic effect

Contact SelectionContact Selection

Generally start with monopolar and shift to Generally start with monopolar and shift to bipolar if limited by side effects at low thresholds bipolar if limited by side effects at low thresholds since bipolar reduces volume of stim (assuming since bipolar reduces volume of stim (assuming parity of other settings) and is thus generally parity of other settings) and is thus generally better tolerated but a little weaker.better tolerated but a little weaker.

If significant limitations even in bipolar, consider If significant limitations even in bipolar, consider assessing lead location with imagingassessing lead location with imaging

Familiarize yourself with where neurosurgeon Familiarize yourself with where neurosurgeon generally implants the basegenerally implants the base

03 12

-

+

03 12

++ -

03 12

-+- +

03 12

- +

AmplitudeAmplitude

Effective voltage usually between 1-3.5VEffective voltage usually between 1-3.5V

If you youIf you you’’re above 3.6v, consider increasing re above 3.6v, consider increasing PW or adding an adjacent contact to reduce PW or adding an adjacent contact to reduce voltage if possiblevoltage if possible

In rare cases you may need to go into 4-5v In rare cases you may need to go into 4-5v range even after increasing PWrange even after increasing PW

Avoid the urge to Avoid the urge to ““turn up the juiceturn up the juice”” each visit. each visit. Higher settings do not equal greater efficacy.Higher settings do not equal greater efficacy.

Pulse WidthPulse Width

60ms works for the majority of cases60ms works for the majority of cases

For severe tremor patients, 90ms (and For severe tremor patients, 90ms (and occasionally 120ms) may be necessary to avoid occasionally 120ms) may be necessary to avoid using a high voltage. Rarely require > 120using a high voltage. Rarely require > 120

PD patients with significant dyskinesias and/or PD patients with significant dyskinesias and/or dystonia may also benefit from higher PW but dystonia may also benefit from higher PW but would start with 60 and re-evaluate patient would start with 60 and re-evaluate patient ON/ON before increasingON/ON before increasing

FrequencyFrequency

Frequency of 130Hz or higher is generally felt to Frequency of 130Hz or higher is generally felt to be most effective for the cardinal motor features.be most effective for the cardinal motor features.

The benefits of going > 130Hz are often minor The benefits of going > 130Hz are often minor but increases represent an opportunity for but increases represent an opportunity for further tweaking when approaching high V/PWfurther tweaking when approaching high V/PW

Some evidence that lower F (e.g. 60Hz) may Some evidence that lower F (e.g. 60Hz) may benefit gait in PD and DYT1 dystonia. Can be benefit gait in PD and DYT1 dystonia. Can be considered when lack of efficacy or side effects considered when lack of efficacy or side effects using higher Fusing higher F

Typical Stimulation ParametersTypical Stimulation Parameters

Parameter STN GPi VIM

Amplitude 1.0 – 3.6 V 2.0 – 3.6 V 1.5 – 3.6 V

Pulse Width 60-90 µsec 90-120 µsec 90-120 µsec

Rate 135 – 185 Hz 135 – 185 Hz 135 – 185 Hz

Electrode Configuration

Unipolar: single electrode or 2 adjacent electrodes

Bipolar: 2 adjacent electrodes





Pre-Surgical ConsiderationsPre-Surgical Considerations

Patient SelectionPatient Selection

Lead LocationLead Location

Pre-Operative AssessmentsPre-Operative Assessments

Defining the team rolesDefining the team roles

Closing the loop with referral sourceClosing the loop with referral source

Patient SelectionPatient Selection

Regardless of the indication, the Regardless of the indication, the importance of optimal patient selection importance of optimal patient selection cannot be overemphasized!cannot be overemphasized!– Screen for appropriate diagnosisScreen for appropriate diagnosis– Screen for appropriate medication trialsScreen for appropriate medication trials– Screen for responsiveness of sx to DBSScreen for responsiveness of sx to DBS– Screen for red flags and contraindicationsScreen for red flags and contraindications– Screen for realistic expectationsScreen for realistic expectations– Screen for understanding and supportScreen for understanding and support

How can DBS Therapy help me How can DBS Therapy help me Achieve Daily Victories?Achieve Daily Victories?

DBS for ETDBS for ET

Della Flora, Mov Dis 2010

Patient Selection: ETPatient Selection: ET

Establish/confirm diagnosisEstablish/confirm diagnosis

Review medication trialsReview medication trials

Assess/document severity and impairmentAssess/document severity and impairment

Review expectationsReview expectations

Essential Tremor: DiagnosisEssential Tremor: Diagnosis

Confirm the diagnosisConfirm the diagnosis– Pure action tremor or mixed action/restPure action tremor or mixed action/rest– What body parts involved/troublesomeWhat body parts involved/troublesome– Any other parkinsonian featuresAny other parkinsonian features– Any evident ataxic componentAny evident ataxic component– Assess tandem gait, balance, speechAssess tandem gait, balance, speech– Establish what positions bring out maximal Establish what positions bring out maximal

tremor and what tasks most impacted tremor and what tasks most impacted – Imaging for evidence of secondary causeImaging for evidence of secondary cause

Essential Tremor: MedicationsEssential Tremor: MedicationsBeta-blockers and primidone are mainstays.Beta-blockers and primidone are mainstays.Both should have been tried at reasonable Both should have been tried at reasonable doses with documentation of max tolerated doses with documentation of max tolerated dose or reasons contraindicated.dose or reasons contraindicated.– Primidone can be Primidone can be >> 750mg in divided doses 750mg in divided doses– No specific beta-blocker but max tolerated within No specific beta-blocker but max tolerated within

usual effective range for given choiceusual effective range for given choice– Combo of both if high doses not toleratedCombo of both if high doses not tolerated

Trials of gabapentin, topirimate, benzo and Trials of gabapentin, topirimate, benzo and sodium oxybate can be consideredsodium oxybate can be consideredBotulinum for head tremorsBotulinum for head tremors

Essential Tremor: SeverityEssential Tremor: SeverityWhen is a tremor severe enough?When is a tremor severe enough?– Does the patient consider it mild, moderate or severe Does the patient consider it mild, moderate or severe

and why?and why?– What ADLs are impacted and to what extent?What ADLs are impacted and to what extent?

Eat with spoon, cutting, with assistEat with spoon, cutting, with assist

Drink with straw, two hands, half filledDrink with straw, two hands, half filled

Writing at all legible, typing impactedWriting at all legible, typing impacted

Other specific ADLs that are impacted and whether they are Other specific ADLs that are impacted and whether they are important to work, social functionimportant to work, social function

– What is the social impact?What is the social impact?Avoidance of activities, embarrassment in social or work Avoidance of activities, embarrassment in social or work eventsevents

Essential Tremor: RatingEssential Tremor: Rating

Video tape position that brings out tremor Video tape position that brings out tremor maximally and specific impaired tasksmaximally and specific impaired tasks

Fahn-Tolosa, TETRAS or other rating scaleFahn-Tolosa, TETRAS or other rating scale

Spiral and simple sentence (upper tremor)Spiral and simple sentence (upper tremor)

Cup to mouth or cup transfer documenting Cup to mouth or cup transfer documenting rough % spill with standard cup sizerough % spill with standard cup size

Sustained Sustained ““eeeeeeee”” or other for voice or other for voice

Video Front/profile for headVideo Front/profile for head

Tremor ScaleTremor ScaleTremor Scale Description

0 Absent (no tremor or writing impairment)

1 Slight and infrequently present (mild tremor, writing, and drawing of spiral minimally impaired)

2 Moderate; bothersome to most patients (writing and drawing of spiral moderately impaired)

3 Severe tremor (writing and drawing severely impaired; interferes with many activities such as drinking liquids)

4 Marked tremor (interferes with most activities)

Available at http://www.wemove.org/et/et_ts.html. Accessed June 3, 2012.

http://www.wemove.org/et/et_ts.html

ET TremorET Tremor

ET-Intraoperative considerationsET-Intraoperative considerations

MER utilized or not? Sensory followed by MER utilized or not? Sensory followed by Motor or straight to motor nucleus (VIM)?Motor or straight to motor nucleus (VIM)?– If MER performed, was face, hand, foot-specific If MER performed, was face, hand, foot-specific

responsiveness identified?responsiveness identified?

Any tremor-response in OR and if so was it Any tremor-response in OR and if so was it clear if lower or higher contacts best?clear if lower or higher contacts best?

Any stim-related side effects elicited and if Any stim-related side effects elicited and if so, what were thresholds?so, what were thresholds?

Any post-operative issues or imaging?Any post-operative issues or imaging?

VIM Lead Placement for tremorVIM Lead Placement for tremor

VIM MappingVIM Mapping

MER-guided multiple trajectory approachMER-guided multiple trajectory approach

Axial View

•Posterior-Anterior Progression:

•Multiple trajectories

•VC (posterior) - VIM (anterior)

•Somatotopy preserved

ET Initial ProgrammingET Initial Programming

Ideally off medications but often not a major Ideally off medications but often not a major factor given ltd efficacy in mostfactor given ltd efficacy in mostStandard tasks that do not overly fatigue Standard tasks that do not overly fatigue (e.g., spirals, finger-nose, sustention)(e.g., spirals, finger-nose, sustention)Start with standard PW (60 or 90) and F Start with standard PW (60 or 90) and F (130-185) and march slowly up voltages by (130-185) and march slowly up voltages by 0.5v increments starting with C+0- up to C+3- 0.5v increments starting with C+0- up to C+3- even if effective with C+0-even if effective with C+0-Try to be consistent, especially in labeling: Try to be consistent, especially in labeling: Specify L VIM, L IPG or R body in notesSpecify L VIM, L IPG or R body in notes

ET Initial Programming ContET Initial Programming Cont

Document benefit and side effect thresholds Document benefit and side effect thresholds for each contactfor each contact

If side effects, wait to see if abate before If side effects, wait to see if abate before abandoning the contact (especially if vague abandoning the contact (especially if vague or sensory in nature unless severe)or sensory in nature unless severe)

If effective, observe for breakthrough and If effective, observe for breakthrough and less evident side effects like speech/balanceless evident side effects like speech/balance

ET PROGRAMMING MOVIEET PROGRAMMING MOVIE

See VideoSee Video

Initial Programming Notes, Case 1Initial Programming Notes, Case 1

L IPGL IPG PW 60PW 60 F145F145– C+0-: C+0-: Reduced tremor 2.5, persistent paresthesias 3.5Reduced tremor 2.5, persistent paresthesias 3.5

– C+1-: C+1-: Reduced at 1.5, best at 2.5 well tol to 3.5**Reduced at 1.5, best at 2.5 well tol to 3.5**

– C+2-: C+2-: Less effective but well tolerated to 3.5Less effective but well tolerated to 3.5

– C+3-: C+3-: Vague SE at 3.5, no clear impact on tremorVague SE at 3.5, no clear impact on tremor

Initial Programming Notes, Case 1Initial Programming Notes, Case 1

L IPGL IPG PW 60PW 60 F145F145– C+0-: C+0-: Reduced tremor 2.5, persistent paresthesias 3.5Reduced tremor 2.5, persistent paresthesias 3.5

– C+1-: C+1-: Reduced at 1.5, best at 2.5 well tol to 3.5**Reduced at 1.5, best at 2.5 well tol to 3.5**

– C+2-: C+2-: Less effective but well tolerated to 3.5Less effective but well tolerated to 3.5

– C+3-: C+3-: Vague SE at 3.5, no clear impact on tremorVague SE at 3.5, no clear impact on tremor

Final Impression: C+0- and 1- best with Final Impression: C+0- and 1- best with preference for 1- given tolerabilitypreference for 1- given tolerability

Initial Programming Notes, case 2Initial Programming Notes, case 2

L IPGL IPG PW 60PW 60 F 145F 145– C+0-C+0- well tolerated but no benefit at 4vwell tolerated but no benefit at 4v– C+1-C+1- similar to 0-similar to 0-– C+2-C+2- speech trouble at 3v, no benefitspeech trouble at 3v, no benefit– C+3-C+3- speech trouble at 2.5-3v, no benefitspeech trouble at 2.5-3v, no benefit



Tried C+0- and 1- with PW90: some benefit Tried C+0- and 1- with PW90: some benefit (1->0-) but speech at 3.5(1->0-) but speech at 3.50+1- improved tremor at 3.5/90/185, well 0+1- improved tremor at 3.5/90/185, well toleratedtolerated



Tried C+0- and 1- with PW90: some benefit (1->0-) Tried C+0- and 1- with PW90: some benefit (1->0-) but speech at 3.5but speech at 3.50+1- improved tremor at 3.5/90/185, well tolerated0+1- improved tremor at 3.5/90/185, well tolerated

Final Impression: Lower leads better but limiting Final Impression: Lower leads better but limiting side effects in monopolar, decent with 0+1-side effects in monopolar, decent with 0+1-

Programming for ET: Programming for ET: TroubleshootingTroubleshooting

ET programming is usually straightforward ET programming is usually straightforward but you can hit limitations due to speech or but you can hit limitations due to speech or balance even with a well-positioned lead balance even with a well-positioned lead and especially with bilateral stim and especially with bilateral stim – DBS is approved for unilateral stim but often DBS is approved for unilateral stim but often

used for bilateralused for bilateral

Identify whether the problem is stimulation Identify whether the problem is stimulation or disease-related (e.g., observe stim off)or disease-related (e.g., observe stim off)Assess whether higher, lower or no stim Assess whether higher, lower or no stim makes problem better or worse if not clearmakes problem better or worse if not clear

Advanced Programming for ET 1:Advanced Programming for ET 1:Poor Tremor Control Poor Tremor Control

When monopolar is not effective despite When monopolar is not effective despite going up to 90ms, try 120ms. If still not going up to 90ms, try 120ms. If still not effective by 150ms despite F up to 185, effective by 150ms despite F up to 185, higher PW are rarely the answer:higher PW are rarely the answer:– Consider two adjacent contacts or even 3 or 4Consider two adjacent contacts or even 3 or 4– If then limited by side effects but some If then limited by side effects but some

efficacy, can try using 2 or 3 electrodes in efficacy, can try using 2 or 3 electrodes in bipolar mode (e.g., 3+0-1-) or interleavingbipolar mode (e.g., 3+0-1-) or interleaving

Advanced Programming for ET 2:Advanced Programming for ET 2:Poor TolerabilityPoor Tolerability

If not well tolerated in monopolar and If not well tolerated in monopolar and ineffective in simple bipolar consider:ineffective in simple bipolar consider:– Multiple electrodes in bipolar (3+0- or 2+0-1-)Multiple electrodes in bipolar (3+0- or 2+0-1-)– Interleaving sometimes allows use of monopolar if Interleaving sometimes allows use of monopolar if

split with bipolarsplit with bipolarL VIM1 C+0- 2.5/60/125L VIM1 C+0- 2.5/60/125

L VIM2 2+1- 3.5/90/125L VIM2 2+1- 3.5/90/125

If not well tolerated in simple bipolar:If not well tolerated in simple bipolar:– Consider sandwiching most effective contactConsider sandwiching most effective contact

0+1-2+ may allow for higher settings0+1-2+ may allow for higher settings

DBS for non-ET TremorDBS for non-ET Tremor

DBS has been performed for a number of DBS has been performed for a number of non-ET tremor disordersnon-ET tremor disorders– MS tremorMS tremor– Holmes/post-stroke tremorHolmes/post-stroke tremor– Dystonic and myoclonic tremorDystonic and myoclonic tremor– Metabolic/genetic tremor syndromesMetabolic/genetic tremor syndromes– Orthostatic tremorOrthostatic tremor

Non-ET TremorNon-ET Tremor

The programming approach is similar to The programming approach is similar to that of ET but the results tend to be less that of ET but the results tend to be less uniform and significantly impacted by non-uniform and significantly impacted by non-tremor pathology that may continue to tremor pathology that may continue to impair ADLs.impair ADLs.– In MS, for example, ataxia often overwhelms In MS, for example, ataxia often overwhelms

the benefit accrued from reduction of tremorthe benefit accrued from reduction of tremor– Proximal tremors may be harder to control Proximal tremors may be harder to control

than distally predominant tremorsthan distally predominant tremors

Differentiating between tremor Differentiating between tremor reduction and functional improvementreduction and functional improvement

Matthieu, 2007

DBS for MS: Short term resultsDBS for MS: Short term results

5 MS patients, mean duration MS 6 yrs, 5 MS patients, mean duration MS 6 yrs, received VIM DBS.received VIM DBS.3 mos follow-up demonstrated 40% reduced 3 mos follow-up demonstrated 40% reduced tremor using modified Fahn tremor using modified Fahn scale/spirographyscale/spirography18% improvement in ADLs18% improvement in ADLsNo adverse outcomesNo adverse outcomesSmall, lacking long term results but Small, lacking long term results but demonstrates safety and potential for benefit demonstrates safety and potential for benefit when tremor is predominant issue.when tremor is predominant issue.

Mandat, Neurol Neurochir Pol, 2010

Long term results: MS TremorLong term results: MS Tremor

12 yr follow-up 9 patients (6 lesion, 3 DBS)12 yr follow-up 9 patients (6 lesion, 3 DBS)Tremor recurred in all except 2 within 3 Tremor recurred in all except 2 within 3 months but those 2 (both in the DBS cohort) months but those 2 (both in the DBS cohort) remained tremor free for 5yremained tremor free for 5yAt yr 12, 5 patients had died (median 5.8y At yr 12, 5 patients had died (median 5.8y post surgery) and the 4 survivors were post surgery) and the 4 survivors were extremely disabled (EDSS 8-8.5).extremely disabled (EDSS 8-8.5).Suggests potential for sustained benefit with Suggests potential for sustained benefit with DBS but ultimately, disease course may DBS but ultimately, disease course may overwhelm benefit.overwhelm benefit.

Hassan, Eur J Neurol, 2012

Specific Concerns: DBS and MSSpecific Concerns: DBS and MS

Potential increased risk of perioperative Potential increased risk of perioperative seizures (2 reported in seizures (2 reported in Johnson, Br J NS 2010Johnson, Br J NS 2010))

Potential for progressive disease/burden of Potential for progressive disease/burden of hemiparesis or ataxia (assess rate of change)hemiparesis or ataxia (assess rate of change)

No clearly reported cases of DBS-induced No clearly reported cases of DBS-induced MS exacerbations but focal demyelination MS exacerbations but focal demyelination may be induced at site of stim (observe post-may be induced at site of stim (observe post-mortem in one case, Moore, MS, 2009)mortem in one case, Moore, MS, 2009)

DBS for MS TremorDBS for MS Tremor

DBS for abeta-lipoproteinemiaDBS for abeta-lipoproteinemia

DBS for ParkinsonDBS for Parkinson’’ss

60 y.o. gentleman 60 y.o. gentleman with 20 years of with 20 years of ParkinsonParkinson’’s, motor s, motor fluctuations and fluctuations and tremors that did not tremors that did not respond well to respond well to levodopa.levodopa.

““IdealIdeal”” PD DBS Candidate PD DBS Candidate

Age: 40-70

Symptomatic for 5-10 years or more

Initial Good Response to L-DOPA

Marked ‘on/off’ phenomena

Dyskinesias

No ON Freezing/Gait Disturbance

Cognitively Intact

PATIENT SELECTION: PDPATIENT SELECTION: PD

Best LD response helps determine benefitBest LD response helps determine benefit

Generally 5 year history to exclude atypicalsGenerally 5 year history to exclude atypicals

No significant neuropsychiatric co-morbidityNo significant neuropsychiatric co-morbidity

No absolute age cut-off but younger is betterNo absolute age cut-off but younger is better

Ability to tolerate surgeryAbility to tolerate surgery

Access to follow-upAccess to follow-up

What are patient expectations?What are patient expectations?

What improves with DBS?What improves with DBS?

Depends on site of stim but the following generally Depends on site of stim but the following generally improve to varying degrees:improve to varying degrees:

Tremor (resting and action)Tremor (resting and action)

RigidityRigidity BradykinesiaBradykinesia DyskinesiasDyskinesias Active > fixed dystoniaActive > fixed dystonia Motor fluctuationsMotor fluctuations

What doesnWhat doesn’’t always improve?t always improve?

Gait may or may not depending on the natureGait may or may not depending on the nature Freezing seldom improves though OFF mayFreezing seldom improves though OFF may Symptoms present when ON medsSymptoms present when ON meds Balance/FallsBalance/Falls Autonomic symptoms (sweating, orthostasis)Autonomic symptoms (sweating, orthostasis) Fixed dystonia/postureFixed dystonia/posture Mood (though OFF anxiety may)Mood (though OFF anxiety may)

What may worsen?What may worsen?

SpeechSpeech (often partly reversible) (often partly reversible) Balance/ataxiaBalance/ataxia (reversible)(reversible) MoodMood (reversible but prescreen for (reversible but prescreen for

SI)SI) WeightWeight (common)(common) Dystonia Dystonia (uncommon)(uncommon)

The in-between candidateThe in-between candidateTry to outline for patients which of their Try to outline for patients which of their

symptoms are likely to persistsymptoms are likely to persistBe wary when complaints include gait and Be wary when complaints include gait and

balance unless ON very different from OFFbalance unless ON very different from OFF– OFF freezing typically segues to ONOFF freezing typically segues to ON– Positive pull test will likely lead to gait limitationsPositive pull test will likely lead to gait limitations

Be wary of very anxious or depressed patients Be wary of very anxious or depressed patients even if you think iteven if you think it’’s PD-relateds PD-related

Be wary of hallucinations even if iatrogenicBe wary of hallucinations even if iatrogenic

N=96 STN, 36=GPiN=96 STN, 36=GPi

NEMJ 2001;345:956-963NEMJ 2001;345:956-963

The Pre-DBS TalkThe Pre-DBS Talk

Review patient expectations clearlyReview patient expectations clearly

– What do you consider your biggest troublesWhat do you consider your biggest troubles– The following should/may/likely wonThe following should/may/likely won’’t improvet improve– Would you be happy if x improved and y didnWould you be happy if x improved and y didn’’tt

– Document this along with avg ON time per dayDocument this along with avg ON time per day

The Pre-DBS talkThe Pre-DBS talk

Review anticipated timelineReview anticipated timeline– Explain itExplain it’’s not a s not a ““light switchlight switch”” and can take and can take

months to achieve optimal settingsmonths to achieve optimal settings– Explain possible microlesion effect and that it Explain possible microlesion effect and that it

may wane over days to weeksmay wane over days to weeks– Explain that reducing meds is often possible Explain that reducing meds is often possible

but is not the goal of surgery…improving and but is not the goal of surgery…improving and extending ON time is the goal extending ON time is the goal

Out-patient follow-up: Out-patient follow-up: Initial programming visitInitial programming visit

Review of all contacts for tolerability & efficacyReview of all contacts for tolerability & efficacy– If available, preview intraoperative macrostimulation results If available, preview intraoperative macrostimulation results

or discuss impression with neurosurgeonor discuss impression with neurosurgeon

Takes about 45m for one side, 90m for bilateral + Takes about 45m for one side, 90m for bilateral + time to observe following medicationstime to observe following medications

Select contacts with optimal effect at lowest settings.Select contacts with optimal effect at lowest settings.Adjustment of medications if/when possibleAdjustment of medications if/when possible

Tools of the Trade

DBS Settings Date: _____________

Left Right

Serial N. _____________ Serial N. _____________

V: 0 PW: 210 F : 30 V: 0 PW: 210 F : 30

Contacts: 3+, 0- Contacts: 3+, 0-

Usage ____/____=____ Reset Usage ____/____=____ Reset

Impedance Check

O-, C+ Imp. ____ Batt. V ____ Current ____ O-, C+ Imp. ____ Batt. V ____

Current ____

1-, C+ Imp. ____ Batt. V ____ Current ____ 1-, C+ Imp. ____ Batt. V ____

Current ____

2-, C+ Imp. ____ Batt. V ____ Current ____ 2-, C+ Imp. ____ Batt. V ____

Current ____ 3-, C+ Imp. ____ Batt. V ____ Current ____ 3-, C+ Imp. ____

Batt. V ____ Current ____

Initial Programming

Left PW: ___ F: ____ Right PW: ___ F: ____

Contact Amp Comments Contact Amp Comments

0-, C+ 0.5 0-, C+ 0.5

1.0 1.0

1.5 1.5

2.0 2.0

2.5 2.5

3.0 3.0

3.5 3.5

4.0 4.0

CONTACT 0 IMPRESSION:

Lead Location DirectlyLead Location DirectlyInfluences Programming: STNInfluences Programming: STN

Thalamus

Substantianigra

dorsal

lateralmedial

ventral

Paresthesias &other sensoryphenomena

diplopia,otheroculomotordisturbances,mydriasis

affective changes

muscular contractions,dysarthria

Reduction of rigidity, tremor,akinesia/bradykinesia,inductin of dyskinesia

STN

GPi

Basic topographyBasic topography

Sensory complaints: posterior or medialSensory complaints: posterior or medialMotor complaints: anterior or lateralMotor complaints: anterior or lateral

Remember that, Remember that, assuming typical angleassuming typical angleof approach, contacts of approach, contacts become increasinglybecome increasinglylateral as you go up.lateral as you go up.

Proper STN Lead PlacementProper STN Lead Placement

STN LEAD PLACEMENT

Average SettingsAverage Settings

For ParkinsonFor Parkinson’’ss– Voltages from 1 to 3.6Voltages from 1 to 3.6– Pulse width from 60-90ms (occas 120)Pulse width from 60-90ms (occas 120)– Frequency from 130-185 HzFrequency from 130-185 Hz

With Soletra, will double current drain above With Soletra, will double current drain above 3.6v so try to maintain below if possible. This 3.6v so try to maintain below if possible. This is not the case with Kinetra, new PC or is not the case with Kinetra, new PC or rechargeable but higher V still drains fasterrechargeable but higher V still drains faster

PROGRAMMING BASICS: IPROGRAMMING BASICS: I

Know the disease and DBS target for Know the disease and DBS target for which youwhich you’’re stimulating!re stimulating!– Vim works mainly for tremorsVim works mainly for tremors– STN and GPi work for tremors, rigidity, STN and GPi work for tremors, rigidity,

bradykinesia, +/- gait and +/- dystoniabradykinesia, +/- gait and +/- dystonia

Make sure you and patient are talking Make sure you and patient are talking same languagesame language– Right symptom versus Right IPGRight symptom versus Right IPG– Tremor versus dyskinesiasTremor versus dyskinesias

PROGRAMMING BASICS: IIPROGRAMMING BASICS: II

Have a good sense of the baseline symptom Have a good sense of the baseline symptom severity off medications before programming.severity off medications before programming.– Use rating scales and/or notesUse rating scales and/or notes

Pick one or two of most evident DBS-responsive Pick one or two of most evident DBS-responsive symptoms to tracksymptoms to track– Rigidity & tremor usually most reliable. Bradykinesia & Rigidity & tremor usually most reliable. Bradykinesia &

gait can be prone to patient fatigue and variabilitygait can be prone to patient fatigue and variability

PROGRAMMING BASICS:IIIPROGRAMMING BASICS:III

As you go through each contact, try to be As you go through each contact, try to be systematic and change only one variable systematic and change only one variable at a time to avoid confusion.at a time to avoid confusion.

Spend time creating a Spend time creating a ““programming maprogramming map.p.”” It will save time in the long-run. It will save time in the long-run.

Identify side effect thresholds and try to Identify side effect thresholds and try to create an image in your mind about lead create an image in your mind about lead placement or at least tolerable limits. placement or at least tolerable limits.

PD PROGRAMMING VIDEOPD PROGRAMMING VIDEO

See Video 2See Video 2

Programming around capsular side effectsProgramming around capsular side effects

Initial Programming SummaryInitial Programming Summary

C+0-C+0- 2.5/60/145 chin pulling2.5/60/145 chin pullingC+1-C+1- 3.5/60/145 mild pull, no change3.5/60/145 mild pull, no changeC+2-C+2- 3.5/60/145 subtle pull, no change3.5/60/145 subtle pull, no changeC+3-C+3- 3.5/60/145 no change, well tol.3.5/60/145 no change, well tol.

--------------------------------------------------------------------------------------------------------------------------------------------C+2- C+2- 2.5/90/145 chin pulling, no change2.5/90/145 chin pulling, no changeC+3- C+3- 3.5/90/145 no change, well tol3.5/90/145 no change, well tol1+2-1+2- 3.5/90/145 mild improvement, well tol3.5/90/145 mild improvement, well tol0+1-2-0+1-2- 3.0/90/1453.0/90/145 tremor improved, well toltremor improved, well tol

Before sending your patient homeBefore sending your patient home

Observe patient ON stim and have them take Observe patient ON stim and have them take their highest scheduled dose of medications.their highest scheduled dose of medications.

Observe for 45-60m. Patient can return if dose Observe for 45-60m. Patient can return if dose failure or canfailure or can’’t wait.t wait.

Generally reduce initial setting (e.g., Generally reduce initial setting (e.g., >>1v below 1v below any side effects) to gauge effect over timeany side effects) to gauge effect over time

Go over Patient Programmer and med planGo over Patient Programmer and med planConsider how many options to allow patientConsider how many options to allow patientDouble check which program theyDouble check which program they’’re leaving onre leaving on

When to return after initial When to return after initial programming?programming?

Generally 2-4 weeks for 2Generally 2-4 weeks for 2ndnd follow-up follow-up unless using multiple groupsunless using multiple groups

After that, depending on symptom and After that, depending on symptom and programming complexity, every 1-3 programming complexity, every 1-3 months until optimized. Avg 4 visits in 6mmonths until optimized. Avg 4 visits in 6m

Once stable, routine follow-up generally Once stable, routine follow-up generally every 4 months or every 6-12 months if every 4 months or every 6-12 months if receiving additional care elsewherereceiving additional care elsewhere

SAMPLE CASESAMPLE CASE

67 year-old gentleman with approximately 17 67 year-old gentleman with approximately 17 years of Parkinsonyears of Parkinson’’s. He has moderate motor s. He has moderate motor fluctuations and dyskinesias. Off time with fluctuations and dyskinesias. Off time with marked left > right tremors, moderate left > right marked left > right tremors, moderate left > right bradykinesia and rigidity, slow gait.bradykinesia and rigidity, slow gait.

Meds: carbidopa/levodopa 25/100 CR tid, Meds: carbidopa/levodopa 25/100 CR tid, 10/100 tid, comtan tid, mirapex 1 bid, 10/100 tid, comtan tid, mirapex 1 bid, amantadine bidamantadine bid

INITIAL PROGRAMMINGINITIAL PROGRAMMING

Left IPG (PW60/F145)Left IPG (PW60/F145)C+0-C+0- good tremor/rigidity reduction by 2.5good tremor/rigidity reduction by 2.5C+1-C+1- good tremor/rigidity reduction by 1.5-2good tremor/rigidity reduction by 1.5-2C+2-C+2- slightly less improvement but good at 2slightly less improvement but good at 2C+3-C+3- no SE, improved tremor> rigno SE, improved tremor> rig

Right IPG (PW60/F145)Right IPG (PW60/F145)C+0- C+0- little baseline sx w/o much change, good tollittle baseline sx w/o much change, good tolC+1-C+1- samesameC+2-C+2- perhaps improvement of mild rig at 2perhaps improvement of mild rig at 2C+3-C+3- little change, well tol to 3.5little change, well tol to 3.5

INITIAL SETTINGSINITIAL SETTINGS

INITIAL SETTINGS:INITIAL SETTINGS:L: C+1- 1.5/60/145L: C+1- 1.5/60/145 R: C+2- 1.5/60/145 R: C+2- 1.5/60/145

Observe ON meds/ON stim for 45min. Looked Observe ON meds/ON stim for 45min. Looked good with mild dyskinesias.good with mild dyskinesias.

Medication plan: Medication plan: carbidopa/levodopa 25/100 CR tid, 10/100 tid, carbidopa/levodopa 25/100 CR tid, 10/100 tid,

comtan tid, mirapex 1 bid, amantadine bidcomtan tid, mirapex 1 bid, amantadine bidDrop comtan. If still dyskinetic or feeling Drop comtan. If still dyskinetic or feeling

better after 1 week, can try dropping mirapex better after 1 week, can try dropping mirapex to daily then off.to daily then off.

FIRST FOLLOW-UP: One monthFIRST FOLLOW-UP: One month

done well, occasional off day, some OFF chin done well, occasional off day, some OFF chin tremor and mild ON dyskinesias but otherwise tremor and mild ON dyskinesias but otherwise has been very happy and has reduced his meds. has been very happy and has reduced his meds. – 25/100CR + 10/100 bid-tid and +/- Mpx 1 PRN25/100CR + 10/100 bid-tid and +/- Mpx 1 PRN

Exam off meds looks very good w/ only chin Exam off meds looks very good w/ only chin tremor and mild LLE rigidity. tremor and mild LLE rigidity.

Bumped up R IPG voltage from 1.5 to 2v which Bumped up R IPG voltage from 1.5 to 2v which helped chin tremor but when observed ON/ON, helped chin tremor but when observed ON/ON, he was clearly more dyskinetic so set slightly he was clearly more dyskinetic so set slightly lower (1.8) and instructed to hold mirapex and lower (1.8) and instructed to hold mirapex and cut 10/100cut 10/100’’s to ½ if possible or if dyskinetic.s to ½ if possible or if dyskinetic.

L: C+1- 1.5/60/145L: C+1- 1.5/60/145 R: C+2- 1.8/60/145 R: C+2- 1.8/60/145

Second Follow-up: 1 mo. laterSecond Follow-up: 1 mo. laterFeels improved though lowering meds more led Feels improved though lowering meds more led

to increased OFF time and still somewhat to increased OFF time and still somewhat bothered by ON dyskinesias. ON/ON exam very bothered by ON dyskinesias. ON/ON exam very good but mild right arm rigidity, mild dyskinesias.good but mild right arm rigidity, mild dyskinesias.

Meds: 25/100 CR + 10/100 AM and PM w/ ½ of Meds: 25/100 CR + 10/100 AM and PM w/ ½ of both at noon, rare Mirapex 1 qD, both at noon, rare Mirapex 1 qD,

Increased L IPG voltage to 2.1, which improved Increased L IPG voltage to 2.1, which improved rigidity but worsened dyskinesias so tried adding rigidity but worsened dyskinesias so tried adding a higher contact, with lower V and did well.a higher contact, with lower V and did well.

Try new setting and see if balance any better by Try new setting and see if balance any better by re-increasing midday 10/100 at noon if balance re-increasing midday 10/100 at noon if balance and gait continue to feel worse than before.and gait continue to feel worse than before.

L: C+1-3- 1.2/60/145L: C+1-3- 1.2/60/145 R: C+2- 2.1/60/145R: C+2- 2.1/60/145

OK, that sounds nice…but…OK, that sounds nice…but…

What to do when no contact seems What to do when no contact seems evidently helpful?evidently helpful?– Pick a contact based on side effect profilePick a contact based on side effect profile– Does seem best tolerated dorsal? ventral?Does seem best tolerated dorsal? ventral?– If still unsure, start with low traditional settings If still unsure, start with low traditional settings

(e.g., C+1- or 2- 1.5/60/145), assess in 2 wks(e.g., C+1- or 2- 1.5/60/145), assess in 2 wks– Consider ON med exam if dyskinesitic patientConsider ON med exam if dyskinesitic patient– DonDon’’t despair (yet)!t despair (yet)!

Follow-up Visits: General Follow-up Visits: General

Check DBS parameters and batteriesCheck DBS parameters and batteries– # of activations# of activations– impedanceimpedance– battery usagebattery usage

Development of stimulation or medication Development of stimulation or medication related side-effectsrelated side-effects

Development of psychiatric and/or Development of psychiatric and/or cognitive changescognitive changes

Use of Patient ParametersUse of Patient Parameters

With new single and dual channel IPGs can With new single and dual channel IPGs can allow patient to increase either V/PW/F (only allow patient to increase either V/PW/F (only one component)one component)

Make sure you set limits and patient is Make sure you set limits and patient is capable of understanding.capable of understanding.

Helpful in allowing them to slowly ramp up Helpful in allowing them to slowly ramp up from a sub-therapeutic start pointfrom a sub-therapeutic start point

Helpful for fine tuning when maximal control Helpful for fine tuning when maximal control of symptoms leads to some side effects (e.g., of symptoms leads to some side effects (e.g., tremor/speech)tremor/speech)

Patient Parameter examplePatient Parameter example

Ideal symptom control at 3v but you note Ideal symptom control at 3v but you note dyskinesias ON/ONdyskinesias ON/ON

Can send patient out at 1v and have them Can send patient out at 1v and have them build up to 2v over next week, reducing build up to 2v over next week, reducing medications if possible and monitoring medications if possible and monitoring dyskinesias or other side effects.dyskinesias or other side effects.

After 1-2 weeks can call with report and After 1-2 weeks can call with report and then go up to 3v if needed.then go up to 3v if needed.

Use of GroupsUse of Groups

Changing groups is a little harder for the Changing groups is a little harder for the patient than changing voltages so make sure patient than changing voltages so make sure patient or caregiver understand/canpatient or caregiver understand/can

Can use A, B, C and D but I advise against > Can use A, B, C and D but I advise against > 2 unless compelling reasons2 unless compelling reasons

Employ different groups when youEmploy different groups when you’’re not sure re not sure which electrode is preferable or different sx which electrode is preferable or different sx respond to different electrodes.respond to different electrodes.

Helpful when you donHelpful when you don’’t have a great handle t have a great handle on optimal settings or limited follow-upon optimal settings or limited follow-up

Use of Group Example 1Use of Group Example 1

Group A: C+1- 2.4/60/145Group A: C+1- 2.4/60/145– Seems to help rigidity and tremor but not gaitSeems to help rigidity and tremor but not gait

Group B: 2+0-1- 3.0/90/185Group B: 2+0-1- 3.0/90/185– Higher V with 1- not well tolerated but ok in Higher V with 1- not well tolerated but ok in

bipolar and bring in 0- to see if helps gaitbipolar and bring in 0- to see if helps gait

Group C: C+1-2- 1.8/60/130Group C: C+1-2- 1.8/60/130– If A and B not helpful, can try addition of 2-If A and B not helpful, can try addition of 2-

Use of Group Example 2Use of Group Example 2

Group A: C+2- 3.0/60/145Group A: C+2- 3.0/60/145– Patient came in with this, happy but some Patient came in with this, happy but some

residual OFF rigidity and ON dyskinesiasresidual OFF rigidity and ON dyskinesiasGroup B: 0-1+2- 3.6/60/145Group B: 0-1+2- 3.6/60/145

– See if introduction of 0- helps added off time See if introduction of 0- helps added off time and change to bipolar causes less ON LIDand change to bipolar causes less ON LID

Group C: Interleave C+2- 3.2/60/125 and Group C: Interleave C+2- 3.2/60/125 and 1+3- 2.0/90/1251+3- 2.0/90/125– See if higher V helps residual OFF but See if higher V helps residual OFF but

addition of 3- offsets possible worsening LIDaddition of 3- offsets possible worsening LID

The challenging case…The challenging case…

Limiting side effects from stimulationLimiting side effects from stimulation– Misplaced or sub-optimally placed lead?Misplaced or sub-optimally placed lead?– Can be compensated for with programming?Can be compensated for with programming?– Consider MRI or discussion with surgeonConsider MRI or discussion with surgeon

Limiting side effectsLimiting side effects

What canWhat can’’t be programmed around?t be programmed around? – Pulling at low settings is very limiting. Can try Pulling at low settings is very limiting. Can try

bipolar but if still pulling, change contactbipolar but if still pulling, change contact– Strong paresthesias that donStrong paresthesias that don’’t abate > 5mt abate > 5m– Evident speech impairmentEvident speech impairment

What can you wait out?What can you wait out?– Mild-moderate paresthesiasMild-moderate paresthesias– Funny but vague light-headed, whoozyFunny but vague light-headed, whoozy

Is the side effect truly stimulator-related?Is the side effect truly stimulator-related?– Assess OFF stim condition if unsureAssess OFF stim condition if unsure

More Creative ProgrammingMore Creative Programming

When getting limiting side effects with When getting limiting side effects with monopolar and not getting adequate control with monopolar and not getting adequate control with bipolar (despite high V and PW), consider bipolar (despite high V and PW), consider sandwiching two electrodes or using wider sandwiching two electrodes or using wider bipolar field:bipolar field:– 0+1-2-3+0+1-2-3+– 0-3+ or 0+3-0-3+ or 0+3-

When higher electrodes improve one symptom When higher electrodes improve one symptom and lower ones another, can try:and lower ones another, can try:– 0-1+3-0-1+3-

The Challenging caseThe Challenging case

OFF symptoms better but remains dyskineticOFF symptoms better but remains dyskinetic– Assess possibility of further med reductionsAssess possibility of further med reductions– Eval ON/ON and program specifically for dyskinesia.Eval ON/ON and program specifically for dyskinesia.– Turn off stim and assess underlying dyskinesias. Is Turn off stim and assess underlying dyskinesias. Is

stim exacerbating or simply not helping dyskinesias?stim exacerbating or simply not helping dyskinesias?If stim exacerbating or causing dyskinesias, If stim exacerbating or causing dyskinesias,

consider different contact, bipolar or lower setting consider different contact, bipolar or lower setting If stim simply not helping, consider raising settings If stim simply not helping, consider raising settings

or alternate contactor alternate contact

Persistent dyskinesiasPersistent dyskinesias

Is DBS improving or exacerbating dyskinesias?Is DBS improving or exacerbating dyskinesias?

Turn DBS OFF in the ON Turn DBS OFF in the ON med state and see impactmed state and see impact

If unclear, push If unclear, push parameters and see if parameters and see if improves or worsensimproves or worsens

If worsening it, consider If worsening it, consider lower settings, bipolar or lower settings, bipolar or different contact (in different contact (in addition or in place)addition or in place)

Stim-driven dyskinesiasStim-driven dyskinesias

InterleavingInterleaving

See interleaving graphicSee interleaving graphic

InterleavingInterleaving

Interleaving involves the rapid alternating Interleaving involves the rapid alternating between two different settings for the between two different settings for the same lead.same lead.

You cannot use the same active contacts You cannot use the same active contacts for program1 and program2for program1 and program2

You must use the same frequency (which You must use the same frequency (which will be reduced as a result) but can vary will be reduced as a result) but can vary the voltage and pulse widththe voltage and pulse width

When to use InterleavingWhen to use Interleaving

You will likely not frequently need itYou will likely not frequently need itConsider when one contact seems best Consider when one contact seems best

but has some side effect limitations when but has some side effect limitations when used exclusivelyused exclusively

Consider it when two very different Consider it when two very different symptoms that respond to different symptoms that respond to different electrodes (e.g., tremor/dyskinesias) but electrodes (e.g., tremor/dyskinesias) but when both electrodes are not well when both electrodes are not well tolerated when used simultaneouslytolerated when used simultaneously

Interleaving sampleInterleaving sample

Setting A: ventral stimSetting A: ventral stim Setting C: dorsal stimSetting C: dorsal stim

Stim-related? Stim-responsive?Stim-related? Stim-responsive?

Ask yourself is the complaint likely to improve with programming?• When in doubt review best med ON exam and consider pushing dose to establish potential for further improvement.•If you suspect something may be caused by DBS, you can always check the symptom with DBS OFF


Lack of improvement despite good tolerabilityLack of improvement despite good tolerability– Are the symptoms normally DBS-responsive?Are the symptoms normally DBS-responsive?– Optimal lead position and adequate stimulation?Optimal lead position and adequate stimulation?– Unrealistic expectations?Unrealistic expectations?– Consider significant programming change, e.g. if Consider significant programming change, e.g. if

stimulating C+1-, try C+3-stimulating C+1-, try C+3-– If still no luck, consider consult with major DBS centerIf still no luck, consider consult with major DBS center


Sudden loss of efficacySudden loss of efficacy– Check IPGCheck IPG’’s both ON, not end of battery life?s both ON, not end of battery life?– Hardware malfunction?Hardware malfunction?– Change in underlying condition?Change in underlying condition?

The Impedance TestThe Impedance Test

Usual Usual rangerange

Short Short circuitcircuit

Open Open circuitcircuit

CurrentCurrent 25-150 25-150 microampsmicroamps

> 250 > 250 microampsmicroamps

<7 <7 microampsmicroamps

ImpedanceImpedance 500-1500500-1500 < 50 ohms< 50 ohms > 2000 > 2000 ohmsohms

If unsure, can contact Medtronic technical support: 800-707-0933

Images of lead fractureImages of lead fracture

Garg et al, 2010

Some Final ThoughtsSome Final Thoughts

Programming remains more art than science but Programming remains more art than science but having a scientific approach makes the art easier.having a scientific approach makes the art easier.

ItIt’’s hard to do harm programming if you keep within s hard to do harm programming if you keep within therapeutic parameters so dontherapeutic parameters so don’’t be timid in t be timid in experimenting with different settings.experimenting with different settings.

Be patient and encourage your patients to be the Be patient and encourage your patients to be the same even if initial programmings are difficult. same even if initial programmings are difficult.

DonDon’’t change or increase settings just for the sake t change or increase settings just for the sake of it or to try and achieve perfection. Donof it or to try and achieve perfection. Don’’t try new t try new settings for things that donsettings for things that don’’t typically respond to t typically respond to changes. At the same time, donchanges. At the same time, don’’t avoid trying new t avoid trying new settings if a patientsettings if a patient’’s status changes.s status changes.

The Rewards of ProgrammingThe Rewards of Programming

Getting comfortable with programming is Getting comfortable with programming is no walk in the park…but once you’ve got no walk in the park…but once you’ve got a handle on it, youa handle on it, you’’ll help others walk ll help others walk through the park with greater ease!through the park with greater ease!

Suggested ReadingsSuggested Readings

Volkmann et al. Basic algorithms for the Volkmann et al. Basic algorithms for the programming of deep brain stimulation in programming of deep brain stimulation in Parkinson's disease. Parkinson's disease. Mov DisordMov Disord 2006; 21 Suppl 2006; 21 Suppl 14:S284-914:S284-9

Okun et al. A case-based review of Okun et al. A case-based review of troubleshooting deep brain stimulator issues in troubleshooting deep brain stimulator issues in movement and neuropsychiatric disorders. movement and neuropsychiatric disorders. Parkinsonism Relat DisordParkinsonism Relat Disord 2008; 14 (7): 532-8 2008; 14 (7): 532-8

Special ThanksSpecial Thanks

NYU: Dr. Mogilner, Maria GillegoNYU: Dr. Mogilner, Maria GillegoMedtronic: Joe Pagano, Annette Carlson, Medtronic: Joe Pagano, Annette Carlson,

Andrea Larson, John Bailey, Kirk FinnisAndrea Larson, John Bailey, Kirk FinnisNANS Team: Peter Hurwitz, Elise Reaves, NANS Team: Peter Hurwitz, Elise Reaves,

Chris WeberChris WeberCo-Presenters: Drs. Charles, Gudesblatt, Co-Presenters: Drs. Charles, Gudesblatt,

Agrawal, Labar, Saper, Rosenow, Oh Agrawal, Labar, Saper, Rosenow, Oh

Thank You!Thank You!

Feel free to follow-up with emails:Feel free to follow-up with emails:

[email protected]

Please remember to leave feedback on how Please remember to leave feedback on how we can improve for future sessions.we can improve for future sessions.

Happy Programming!Happy Programming!

good vibrations : management of deep brain stimulation for et and pd michael pourfar, md co-director...

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