Novel Programming Features Help Alleviate Subthalamic Nucleus Stimulation‐Induced Side Effects

Abstract

A BS TRACT: Background: Subthalamic nucleus deep brain stimulation (STN-DBS) is a widely used treatment for Parkinsonʼs disease (PD) patients with motor complications, but can result in adverse effects (AEs) in a significant proportion of treated patients. The use of novel programming features including short pulse width (PW) and directional steering in alleviating stimulationinduced AEs has not been explored. Objective: To determine if programming with short PW, directional steering, or the combination of these novel techniques can improve stimulation-induced dysarthria, dyskinesia, and pyramidal AEs. Methods: Thirty-two consecutive PD patients who experienced reversible AEs of STN-DBS had optimization of their settings using either short PW, directional steering, or the combination, while ensuring equivalent control of motor symptoms. Pairwise comparisons of pre-and post-optimization adverse effect ratings were made. Patients were left on the alternative setting with the greatest benefit and followed up at 6 months. Modeling of volume of tissue activated (VTA) and charge per pulse (Qp) calculations were used to explore potential underlying mechanisms of any differences found. Results: There were significant improvements in stimulation-induced dysarthria, dyskinesia, and pyramidal side effects after optimization. At 6 months, mean AE ratings remained significantly improved compared to preoptimization ratings. Different patterns of shift in VTA for each AE, and Qp could be used to explain improvements using novel techniques. Conclusions: Stimulation-induced dysarthria, dyskinesia, and pyramidal AEs induced by STN-DBS can be improved by using novel programming techniques. These represent additional tools to conventional methods that can be used to address these AEs.

Quantifying Stridor Associated with Parkinsonism and Deep Brain Stimulation—A Case Report

“…Although the mechanisms underlying stridor in parkinsonian disorders have not been fully elucidated, dystonia in the laryngeal adductor muscles has been a suggested cause. The worsening of stridor with conventional stimulation may represent a stimulation‐induced side effect such as dystonia or hyperadduction of the vocal cords by corticobulbar tract stimulation, 7 and the use of novel stimulation techniques has been shown to alleviate these, 6 corresponding to the improvement in stridor demonstrated in this case.…”

“…Our group previously demonstrated how novel stimulation techniques incorporating short pulse width and directional stimulation can ameliorate adverse effects, including stimulation‐induced dysarthria and dyskinesia, and pyramidal side effects 6 . A systematic monopolar review aiming to reduce stridor while maintaining motor function was carried out using both conventional (60 μs and 130 Hz) and novel approaches including frequency modulation, the use of shorter pulse width (30 μs), and directional screening at the vertical level of the chronically used contacts.…”

A randomized crossover trial of short versus conventional pulse width DBS in Parkinson’s Disease

“…This concept is supported by a recent study by Dayal et al demonstrating an alleviation of dyskinesia by stimulation with 30µs in an acute challenge. 15 An often-discussed benefit of short pulse width stimulation is its reduced charge per pulse. Previous studies hypothesized, that this might result in fewer side-effects and increased battery life.…”

“…This concept is supported by a recent study by Dayal et al demonstrating an alleviation of dyskinesia by stimulation with 30µs in an acute challenge. 15…”

“…[10][11][12][13][14] Additionally, some authors suggested that DBS with shorter pulse widths might reduce energy consumption while maintaining equal symptom control compared to standard pulse width as investigated during an acute challenge design. [10][11][12] Furthermore, DBS with 30µs resulted in an improvement of stimulation-induced dysarthria, dyskinesia, and gait in an acute challenge 14,15 . This beneficial effect on stimulation-induced dysarthria and gait was neither replicated in a double-blinded randomized crossover trial investigating a period of 4 weeks in a cohort of PD patients with stimulation-induced dysarthria, 13 nor in a recent study investigating the effect of short pulse width stimulation on objective gait parameters in an acute challenge.…”