Abstract
Despite substantial experience with deep brain stimulation for movement disorders and recent interest in electrode targeting under general anesthesia, little is known about whether awake macrostimulation during electrode targeting predicts postoperative side effects from stimulation. We hypothesized that intraoperative awake macrostimulation with the newly implanted DBS lead predicts dose-limiting side effects during device activation in clinic. We reviewed 384 electrode implants for movement disorders, characterized the presence or absence of stimulus amplitude thresholds for dose-limiting DBS side effects during surgery, and measured their predictive value for side effects during device activation in clinic with odds ratios ±95% confidence intervals. We also estimated associations between voltage thresholds for side effects within participants. Intraoperative clinical response to macrostimulation led to adjustments in DBS electrode position during surgery in 37.5% of cases (31.0% adjustment of lead depth, 18.2% new trajectory, or 11.7% both). Within and across targets and disease states, dose-limiting stimulation side effects from the final electrode position in surgery predict postoperative side effects, and side effect thresholds in clinic occur at lower stimulus amplitudes versus those encountered in surgery. In conclusion, awake clinical testing during DBS targeting impacts surgical decision-making and predicts dose-limiting side effects during subsequent device activation.
Highlights
Deep brain stimulation (DBS) is effective for motor symptoms of Parkinson’s disease (PD), essential tremor, and dystonia that do not respond to medications and more conventional treatments [1,2,3,4,5]
Our goal was to evaluate whether macrostimulation side effects during surgery across targets (STN, globus pallidus pars interna (GPi), and ventral intermediate thalamus (VIM))
We refined electrode targeting based upon individual anatomy, microelectrode recordings, macrostimulation, and testing with the newly implanted Medtronic 3387 DBS lead
Summary
Deep brain stimulation (DBS) is effective for motor symptoms of Parkinson’s disease (PD), essential tremor, and dystonia that do not respond to medications and more conventional treatments [1,2,3,4,5]. Despite improvement at the group level, outcomes vary substantially in individuals, and surprisingly little is known about whether awake macrostimulation with the DBS electrode during surgery predicts postoperative stimulation side effects. Individual refinement of electrode positioning within these target regions plays an important role in optimizing clinical outcomes. Suboptimal lead placement remains an important problem that can lead to decreased efficacy, unwanted stimulation side effects, time-consuming postoperative programming sessions, and surgical revision to reposition the DBS electrode. During DBS surgery, a linear array of electrode contacts is implanted in the brain, guided initially by anatomy from MR images. Practices vary across centers, lead location is typically refined with single unit microelectrode recordings and/or macrostimulation with the DBS electrode [7,8,9]
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