Deep brain stimulation

Changed by Henry Knipe, 10 Sep 2019

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Deep brain stimulation is used in a variety of clinical settings, predominantly in patients with poorly controlled movement disorders. Although effective, its exact mode of function continues to be poorly understood ².

Careful patient selection and target selection are essential if the procedure is to have good efficacy.

Indications

Parkinson disease
- subthalamic nucleus ¹
- pedunculopontine nucleus
- globus pallidus (pars interna)
severe essential tremor
- ventral intermediate nucleus ²
dystonia (cervical dystonia and tardive dystonia) ⁴
- globus pallidus (pars interna)
cluster headaches ⁶
- hypothalamus
chronic pain ⁵
- thalamus
- periaqueductal grey matter
neuropsychiatric disorders: largely experimental ⁴
- Tourette syndrome
  - centromedian parafascicular complex (thalamus)
- medically refractive depression
  - white-matter tracts adjacent to cingulate gyrus
  - nucleus accumbens
- obsessive-compulsive disorder
  - anterior limb of internal capsule
  - subthalamic nucleus
  - striatum

Procedure

A stereotactic frame is applied and imaging obtained to enable accurate target selection. With the aid of multi-planar reformats and operative stereotaxis, a burr-hole is made for each probe and the electrode passed to the desired target, avoiding the lateral ventricles, vessels and sulci. Intraoperative stimulation is then performed to ensure adequate positioning. Leads are tunnelled under the skin and the internal pulse generator ~~(IPG)~~ implanted in a similar location to a pacemaker.

Complications

Complications ~~usually occur immediately~~can be immediate or ~~shortly after placement and include haemorrhage~~delayed ¹²:

immediate
- haemorrhage (~1.5%)
  - can be secondary to venous infarction
- infarction
- local brain parenchymal oedema (~3%)
  - unilateral or bilateral
  - 4-120 days post-operatively
  - asymptomatic or present with headache, ~~mal-placement, and very rarely infection.~~seizure
delayed
- infection (~12.5%): most commonly the pulse generator pocket
- lead fracture (~10%)

Side effects predominantly relate to the stimulation itself, which may lead to dysarthria, disequilibrium, motor disturbances and ~~paraesthesiae~~paraesthesia. These symptoms will of course vary with the exact location of the probes.

~~-<a title="Cluster headache" href="/articles/cluster-headache">cluster headaches</a> <sup>6</sup><ul><li>hypothalamus</li></ul>~~
+<a href="/articles/cluster-headache">cluster headaches</a> <sup>6</sup><ul><li>hypothalamus</li></ul>
-</ul><h4>Procedure</h4><p>A stereotactic frame is applied and imaging obtained to enable accurate target selection. With the aid of multi-planar reformats and operative stereotaxis, a burr-hole is made for each probe and the electrode passed to the desired target, avoiding the ventricles, vessels and sulci. Intraoperative stimulation is then performed to ensure adequate positioning. Leads are tunnelled under the skin and the internal pulse generator (IPG) implanted in a similar location to a pacemaker.</p><h4>Complications</h4><p>Complications usually occur immediately or shortly after placement and include haemorrhage, mal-placement, and very rarely infection.</p><p>Side effects predominantly relate to the stimulation itself, which may lead to dysarthria, disequilibrium, motor disturbances and paraesthesiae. These symptoms will of course vary with the exact location of the probes.</p>
+</ul><h4>Procedure</h4><p>A stereotactic frame is applied and imaging obtained to enable accurate target selection. With the aid of multi-planar reformats and operative stereotaxis, a burr-hole is made for each probe and the electrode passed to the desired target, avoiding the <a href="/articles/lateral-ventricle-1">lateral ventricles</a>, vessels and sulci. Intraoperative stimulation is then performed to ensure adequate positioning. Leads are tunnelled under the skin and the internal pulse generator implanted in a similar location to a pacemaker.</p><h4>Complications</h4><p>Complications can be immediate or delayed <sup>12</sup>: </p><ul>
+<li>
+<strong>immediate</strong><ul>
+<li>
+<a href="/articles/intracranial-haemorrhage">haemorrhage</a> (~1.5%)<ul><li>can be secondary to <a href="/articles/cerebral-venous-infarction">venous infarction</a>
+</li></ul>
+</li>
+<li><a title="Cerebral infarction" href="/articles/ischaemic-stroke">infarction</a></li>
+<li>local brain parenchymal oedema (~3%)<ul>
+<li>unilateral or bilateral</li>
+<li>4-120 days post-operatively</li>
+<li>asymptomatic or present with headache, seizure</li>
+</ul>
+</li>
+</ul>
+</li>
+<li>
+<strong>delayed</strong><ul>
+<li>infection (~12.5%): most commonly the pulse generator pocket</li>
+<li>lead fracture (~10%)</li>
+</ul>
+</li>
+</ul><p>Side effects predominantly relate to the stimulation itself, which may lead to dysarthria, disequilibrium, motor disturbances and paraesthesia. These symptoms will of course vary with the exact location of the probes.</p>

References changed:

7. Jonathan Sterman, Alain Cunqueiro, R. Joshua Dym, Michael Spektor, Michael L. Lipton, Margarita V. Revzin, Meir H. Scheinfeld. Implantable Electronic Stimulation Devices from Head to Sacrum: Imaging Features and Functions. (2019) RadioGraphics. 39 (4): 1056-1074. <a href="https://doi.org/10.1148/rg.2019180088">doi:10.1148/rg.2019180088</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31283461">Pubmed</a> <span class="ref_v4"></span>

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Deep brain stimulation

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