copy of dbs grand rounds jan 2011
TRANSCRIPT
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Assistant Professor of Surgery Director, Functional and Restorative Neurosurgery University of Connecticut
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(Benabid et al., 1991; Blond et al., 1992)
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DBS
SURGERY
Personnel
Equipment
Space
Interdisciplinary
Collabora>on
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Movement Disorder Neurologist
Neurosurgeon
Psychiatrist Electrophysiologist
Neuropsychologist
Pa9ent
APRNs/ PAs
Anesthesia Team
OR Staff
Neuro-‐ICU Staff Pa9ent
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DBS Lead Extension Implantable Pulse Generator (IPG)
Test Stimulator Clinician Programmer Pt Controller
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Neurosurgeon
Neurologist Psychiatrist
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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
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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
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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
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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)
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Cuny et al, 2002
Ulla et al, 2009
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STN
SNr
Sagieal Sec>on through the Thalamus
Thalamus
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Tremor-‐ Vim
Parkinson’s Disease-‐ STN
Dystonia-‐ Vim or GPi
Emerging targets: Subthalamic white maeer, Paralemniscal Radia>ons, and PPN
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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
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DBS OFF DBS ON
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• >800 published articles on DBS in MDJs • Safety and efficacy demonstrated • Long-term benefits
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• The most common movement disorder
• Big impact on life: – Socially – Professionally – Emo>onally
hep://www.total-‐diet.com/170-‐stress-‐at-‐work/
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• 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
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• 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)
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(Saxena et al., 2002)
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LF Responders = pa>ents with at least a 25% reduc>on in YBOCS at last follow-‐up
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• 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
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IC IC
Caudate Caudate
Putamen
Putamen
AcM
GP
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Region where Subcaudate Tractotomy, Gamma Capsulotomy, and DBS Targets Overlap S. Haber
Medial
Orbital
Dorsolateral Premotor Motor
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• 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
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46 YOF, post-partum end-stage depression of over 10 years, medication-refractory with over 74
Electroconvulsive shock (ECT) treatments
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(Mayberg et al., Neuron, 2005)
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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
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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
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(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
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(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)
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(Stelten et al., 2008)
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(Gao et al., 2003)
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• 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)
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