Microelectrode-guided implantation of deep brain stimulators into the globus pallidus internus for dystonia: techniques, electrode locations, and outcomes

Starr, Philip A.; Turner, Robert S.; Rau, Geoff; Lindsey, Nadja; Heath, Susan; Volz, Monica; Ostrem, Jill L.; Marks, William J.

doi:10.3171/jns.2006.104.4.488

Cited by 239 publications

(235 citation statements)

References 51 publications

(81 reference statements)

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“…57 Prior to recording, all patients were sedated with propofol for placement of the stereotactic frame as well as the surgical incision. Propofol is known to suppress basal ganglia discharge, 23 but is cleared rapidly, and prior studies in PD and dystonia suggest no neuronal effect of propofol following 30-60 minutes of washout time.…”

Section: Methodsmentioning

confidence: 99%

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Pallidal stimulation for Holmes tremor: clinical outcomes and single-unit recordings in 4 cases

Kilbane

Ramirez‐Zamora

Ryapolova-Webb

et al. 2015

JNS

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OBJECT Holmes tremor (HT) is characterized by irregular, low-frequency (< 4.5 Hz) tremor occurring at rest, with posture, and with certain actions, often affecting proximal muscles. Previous reports have tended to highlight the use of thalamic deep brain stimulation (DBS) in cases of medication-refractory HT. In this study, the authors report the clinical outcome and analysis of single-unit recordings in patients with medication-refractory HT treated with globus pallidus internus (GPi) DBS. METHODS The authors retrospectively reviewed the medical charts of 4 patients treated with pallidal DBS for medication-refractory HT at the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center. Clinical outcomes were measured at baseline and after surgery using an abbreviated motor-severity Fahn-Tolosa-Marin (FTM) tremor rating scale. Intraoperative microelectrode recordings were performed with patients in the awake state. The neurophysiological characteristics identified in HT were then also compared with characteristics previously described in Parkinson's disease (PD) studied at the authors' institution. RESULTS The mean percentage improvement in tremor motor severity was 78.87% (range 59.9%–94.4%) as measured using the FTM tremor rating scale, with an average length of follow-up of 33.75 months (range 18–52 months). Twenty-eight GPi neurons were recorded intraoperatively in the resting state and 13 of these were also recorded during contralateral voluntary arm movement. The mean firing rate at rest in HT was 56.2 ± 28.5 Hz, and 63.5 ± 19.4 Hz with action, much lower than the GPi recordings in PD. GPi unit oscillations of 2–8 Hz were prominent in both patients with HT and those with PD, but in HT, unlike PD, these oscillations were not suppressed by voluntary movement. CONCLUSIONS The efficacy of GPi DBS exceeded that reported in prior studies of ventrolateral thalamus DBS and suggest GPi may be a better target for treating HT. These clinical and neurophysiological findings help illuminate evolving models of HT and highlight the importance of cerebellar–basal ganglia interactions.

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Section: Methodsmentioning

confidence: 99%

“…46 The MR images were computationally reformatted to be orthogonal to the anterior commissure-posterior commissure (AC-PC) line and midsagittal plane 57 (Framelink software, version 4.1, Medtronic), and lead tip locations were measured with respect to the midcommissural point ( Table 2, Fig. 1).…”

Section: Lead Locationsmentioning

confidence: 99%

Pallidal stimulation for Holmes tremor: clinical outcomes and single-unit recordings in 4 cases

Kilbane

Ramirez‐Zamora

Ryapolova-Webb

et al. 2015

JNS

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“…38 Other groups have proposed that microelectrode recording provides important information for adequate lead placement in the GPi. 3,35 Starr et al have shown good lead placement in a mixed group of patients with different types of dystonia using microelectrode recording with few serious complications. 35 They have shown that even in patients who needed to be under general anesthesia they could achieve adequate mapping, but cautioned that propofol and inhalational agents should be avoided for optimal preservation of neuronal firing.…”

mentioning

confidence: 99%

“…3,35 Starr et al have shown good lead placement in a mixed group of patients with different types of dystonia using microelectrode recording with few serious complications. 35 They have shown that even in patients who needed to be under general anesthesia they could achieve adequate mapping, but cautioned that propofol and inhalational agents should be avoided for optimal preservation of neuronal firing. 35 Dexmedetomidine has been successfully used during DBS surgery in dystonic children, providing adequate sedation and analgesia without causing respiratory depression and allowing for patient cooperation during neurophysiological mapping.…”

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Deep brain stimulation in children and young adults with secondary dystonia: the Children's Hospital Los Angeles experience

Olaya

Christian

Ferman

et al. 2013

FOC

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Background Dystonia is a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both. It can be classified as primary or secondary. There is no cure for dystonia and the goal of treatment is to provide a better quality of life for the patient. Surgical intervention is considered for patients in whom an adequate trial of medical treatment has failed. Deep brain stimulation (DBS), specifically of the globus pallidus interna (GPi), has been shown to be extremely effective in primary generalized dystonia. There is much less evidence for the use of DBS in patients with secondary dystonia. However, given the large number of patients with secondary dystonia, the significant burden on the patients and their families, and the potential for DBS to improve their functional status and comfort level, it is important to continue to investigate the use of DBS in the realm of secondary dystonia. Object The objective of this study is to review a series of cases involving patients with secondary dystonia who have been treated with pallidal DBS. Methods A retrospective review of 9 patients with secondary dystonia who received treatment with DBS between February 2011 and February 2013 was performed. Preoperative and postoperative videos were scored using the Barry-Albright Dystonia Scale (BADS) and Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) by a neurologist specializing in movement disorders. In addition, the patients' families completed a subjective questionnaire to assess the perceived benefit of DBS. Results The average age at DBS unit implantation was 15.1 years (range 6–20 years). The average time to follow-up for the BADS evaluation from battery implantation was 3.8 months (median 3 months). The average time to follow-up for the subjective benefit evaluation was 10.6 months (median 9.5 months). The mean BADS scores improved by 9% from 26.5 to 24 (p = 0.04), and the mean BFMDRS scores improved by 9.3% (p = 0.055). Of note, even in patients with minimal functional improvement, there seemed to be decreased contractures and spasms leading to improved comfort. There were no complications such as infections or hematoma in this case series. In the subjective benefit evaluation, 3 patients' families reported “good” benefit, 4 reported “minimal” benefit, and 1 reported no benefit. Conclusions These early results of GPi stimulation in a series of 9 patients suggest that DBS is useful in the treatment of secondary generalized dystonia in children and young adults. Objective improvements in BADS and BFMDRS scores are demonstrated in some patients with generalized secondary dystonia but not in others. Larger follow-up studies of DBS for secondary dystonia, focusing on patient age, history, etiology, and patterns of dystonia, are needed to learn which patients will respond best to DBS.

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“…16 Anesthetics such as benzodiazepines, barbiturates, propofol, etomidate, and volatile agents potentiate the postsynaptic GABA effects by several actions that create an increased "open probability" for the GABA receptor channels. 17 Recent animal work on normal and MPTP-treated mice has shown abundant GABAergic innervations and GABA receptors in globus pallidus and that the endogenous GABA receptors modulate the spontaneous firing of globus pallidus neurons in normal mice. 3 Active spontaneous neuroelectrical firing from the globus pallidus is exceptionally sensitive to even small doses of anesthetic agents due to a large GABAergic input from the striatum.…”

Section: Discussionmentioning

confidence: 99%

Preservation of microelectrode recordings with non–GABAergic drugs during deep brain stimulator placement in children

Hippard¹,

Watcha²,

Stocco

et al. 2014

PED

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Object Deep brain stimulation (DBS) has become accepted therapy for intractable dystonia and other movement disorders. The accurate placement of DBS electrodes into the globus pallidus internus is assisted by unimpaired microelectrode recordings (MERs). Many anesthetic and sedative drugs interfere with MERs, requiring the patient to be awake for target localization and neurological testing during the procedure. In this study, a novel anesthetic technique was investigated in pediatric DBS to preserve MERs. Methods In this paper, the authors describe a sedative/anesthetic technique using ketamine, remifentanil, dexmedetomidine, and nicardipine in 6 pediatric patients, in whom the avoidance of GABAergic stimulating drugs permitted excellent surgical conditions with no detrimental effects on intraoperative MERs. The quality of the MERs, and the frequency of its use in making electrode placement decisions, was reviewed. Results All 6 patients had good-quality MERs. The data were of sufficient quality to make a total of 9 trajectory adjustments. Conclusions Microelectrode recordings in pediatric DBS can be preserved with a combination of dexmedetomidine and ketamine, remifentanil, and nicardipine. This preservation of MERs is particularly crucial in electrode placement in children.

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Microelectrode-guided implantation of deep brain stimulators into the globus pallidus internus for dystonia: techniques, electrode locations, and outcomes

Cited by 239 publications

References 51 publications

Pallidal stimulation for Holmes tremor: clinical outcomes and single-unit recordings in 4 cases

Pallidal stimulation for Holmes tremor: clinical outcomes and single-unit recordings in 4 cases

Deep brain stimulation in children and young adults with secondary dystonia: the Children's Hospital Los Angeles experience

Preservation of microelectrode recordings with non–GABAergic drugs during deep brain stimulator placement in children

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