Deep Brain Stimulation Centers Research Articles

Establishing First Deep Brain Stimulation Center in United Arab Emirates: Challenges and Initial Experience

Establishing First Deep Brain Stimulation Center in United Arab Emirates: Challenges and Initial Experience

Complications Related to Deep Brain Stimulation Lead Implantation: A Single-Surgeon Case Series.

Deep brain stimulation (DBS) is the mainstay of surgical treatment for movement disorders, yet previous studies have shown widely varying complication rates. Given the elective nature of DBS surgery, minimizing surgical complications is imperative. To evaluate short-term and long-term complications related to DBS lead implantation surgeries performed by an experienced surgeon and provide an updated benchmark comparison for other DBS centers and alternative therapies. A retrospective chart review of patients who underwent DBS lead implantation surgery by a single surgeon at our institution between 2012 and 2020 was conducted. Demographic and clinical data including surgical complications were collected. A Kaplan-Meier survival analysis was used to evaluate the cumulative risk of lead revision or removal over time. Associations between patient characteristics and various complications were evaluated. Four hundred fifty-one DBS leads were placed in 255 patients. Thirteen leads and 11 patients required revision. In total, 3.6% (95% CI [1.3%-5.9%]) of patients required revision at 1 year and 4.8% (95% CI [1.9%-7.6%]) at 5 years, with per-lead revision rates of 2.3% (95% CI [0.9%-3.6%]) and 3.3% (95% CI [1.5%-5.1%]), respectively. Less common diagnoses such as Tourette syndrome, post-traumatic tremor, and cluster headache trended toward association with lead revision or removal. DBS performed by an experienced surgeon is associated with extremely low complication rates.

Automatic extraction of upper-limb kinematic activity using deep learning-based markerless tracking during deep brain stimulation implantation for Parkinson's disease: A proof of concept study.

Optimal placement of deep brain stimulation (DBS) therapy for treating movement disorders routinely relies on intraoperative motor testing for target determination. However, in current practice, motor testing relies on subjective interpretation and correlation of motor and neural information. Recent advances in computer vision could improve assessment accuracy. We describe our application of deep learning-based computer vision to conduct markerless tracking for measuring motor behaviors of patients undergoing DBS surgery for the treatment of Parkinson’s disease. Video recordings were acquired during intraoperative kinematic testing (N = 5 patients), as part of standard of care for accurate implantation of the DBS electrode. Kinematic data were extracted from videos post-hoc using the Python-based computer vision suite DeepLabCut. Both manual and automated (80.00% accuracy) approaches were used to extract kinematic episodes from threshold derived kinematic fluctuations. Active motor epochs were compressed by modeling upper limb deflections with a parabolic fit. A semi-supervised classification model, support vector machine (SVM), trained on the parameters defined by the parabolic fit reliably predicted movement type. Across all cases, tracking was well calibrated (i.e., reprojection pixel errors 0.016–0.041; accuracies >95%). SVM predicted classification demonstrated high accuracy (85.70%) including for two common upper limb movements, arm chain pulls (92.30%) and hand clenches (76.20%), with accuracy validated using a leave-one-out process for each patient. These results demonstrate successful capture and categorization of motor behaviors critical for assessing the optimal brain target for DBS surgery. Conventional motor testing procedures have proven informative and contributory to targeting but have largely remained subjective and inaccessible to non-Western and rural DBS centers with limited resources. This approach could automate the process and improve accuracy for neuro-motor mapping, to improve surgical targeting, optimize DBS therapy, provide accessible avenues for neuro-motor mapping and DBS implantation, and advance our understanding of the function of different brain areas.

A novel deep learning model for STN localization from LFPs in Parkinson’s disease

Deep brain stimulation (DBS) is a common treatment for the neurological disorder, Parkinson’s disease (PD). DBS encompasses accurate implantation of stimulated electrodes at subthalamic nucleus (STN). Although imaging modalities are basically employed to identify STN boundaries, additional electrophysiological signals, microelectrode recording (MER), are important to deduce the underlying anatomy. Despite the adequate clinical outcomes, MER jeopardizes the patient safety. Recently, local field potentials (LFP) gained attention for STN detection due to their correlation with the motor territory of STN and ability to expose valuable insight into PD mechanisms. We propose a novel model, called CNN-GA-KNN, that improves the accuracy of STN localization using LFP. Convolutional neural network (CNN) model is used to extract deep local features. The generated features are fed to genetic algorithm (GA) technique for feature selection. The most distinguishing features are used as input of k-Nearest Neighbour (KNN) classifier, developed using leave-one-out strategy. Results show that KNN reached an average accuracy of 87.27%, outperforming the existing feature extraction techniques. CNN-GA-KNN betters five end-to-end deep learning approaches, yielding significant improvements in classification accuracy up to 7.47%, 8.48%, 7.06%, 6.93% and 6.86% in comparison to LSTM-CNN, GRU-CNN, BiLSTM-CNN, VGG16 and ResNet18, respectively. Results strongly imply that CNN-GA-KNN has tremendous potential to divulge informative features concerning STN taking advantage of a robust feature extraction strategy that combines the repeatability and learnability of GA and KNN. The system is ready to assist as an additional tool for fine-tuning the electrode trajectory in DBS centers instead of the current framework utilizing MER.

Gender gap in deep brain stimulation for Parkinson\u2019s disease

Previous studies have shown less access to deep brain stimulation (DBS) for Parkinson’s disease (PD) in women compared to men raising concerns about a potential gender gap resulting from nonclinical factors or gender differences in clinical efficacy for postoperative quality of life (QoL), motor, and nonmotor symptoms (NMS) outcomes. This was a cross-sectional and a longitudinal, prospective, observational, controlled, quasi-experimental, international multicenter study. A total sample size of 505 consisted of 316 consecutively referred patients for DBS indication evaluation at the University Hospital Cologne (01/2015–09/2020) and 189 consecutively treated patients at DBS centers in the University Hospitals Cologne and Marburg, Salford’s Royal Hospital Manchester, and King’s College Hospital London. In the cross-sectional cohort, we examined gender proportions at referral, indication evaluations, and DBS surgery. In the longitudinal cohort, clinical assessments at preoperative baseline and 6-month follow-up after surgery included the PD Questionnaire-8, NMSScale, Scales for Outcomes in PD-motor scale, and levodopa-equivalent daily dose. Propensity score matching resulted in a pseudo-randomized sub-cohort balancing baseline demographic and clinical characteristics between women with PD and male controls. 316 patients were referred for DBS. 219 indication evaluations were positive (women n = 102, respectively n = 82). Women with PD were disproportionally underrepresented in referrals compared to the general PD population (relative risk [RR], 0.72; 95%CI, 0.56–0.91; P = 0.002), but more likely to be approved for DBS than men (RR, 1.17; 95%CI, 1.03–1.34; P = 0.029). Nonetheless, their total relative risk of undergoing DBS treatment was 0.74 (95%CI, 0.48–1.12) compared to men with PD. At baseline, women had longer disease duration and worse dyskinesia. Exploring QoL domains, women reported worse mobility and bodily discomfort. At follow-up, all main outcomes improved equally in both genders. Our study provides evidence of a gender gap in DBS for PD. Women and men with PD have distinct preoperative nonmotor and motor profiles. We advocate that more focus should be directed toward the implementation of gender equity as both genders benefit from DBS with equal clinical efficacy. This study provides Class II evidence of beneficial effects of DBS in women with PD compared to male controls.

P 18 Can connectivity link the effects of STN and VIM DBS across tremor-related diseases? A multi-cohort functional connectivity study

Introduction: Tremor is defined as an involuntary, rhythmic oscillatory movement of a body part and represents one of the most common symptoms in movement disorders, existing across several diseases. Particularly, in advanced states of tremor-related diseases such as Parkinson’s disease (PD) and Essential tremor syndrome (ET), response to pharmacotherapy can be insufficient and side effects may occur. In recent decades, deep brain stimulation (DBS) of the ventro-intermediolateral nucleus (VIM) and the subthalamic nucleus (STN) has become an established treatment option that can lead to alleviation of tremor in ET and PD patients, respectively. It is known that correlates of structural connections, such as the dentato-rubro-thalamic tract, are beneficial in tremor syndromes during stimulation, whereas information on the exact functional networks associated with optimal tremor response is lacking. However, analysis of connectivity profiles has been shown to reveal associations between electrode localization and clinical improvement in both PD and ET patients with DBS, and is therefore a powerful tool for investigating further disease- and possibly symptom-specific networks. Objective: Our aim is to investigate functional cerebral tremor networks of a multi-center cohort of PD- and ET-patients considering different surgical DBS targets. Patients & Methods: A total of 113 PD patients from DBS centers Berlin, Würzburg and Amsterdam with STN DBS were included in our study. In the STN DBS cohort, patients without tremor at baseline (< 3 points on UPDRS) were excluded from further analysis. The ET cohort consisted of 36 ET patients with VIM DBS. DBS electrodes in all patients were localized using Lead-DBS software. Seeding from voxels contained in the volume of activated tissue, a functional connectivity profile was calculated followed by voxel-wise correlation of clinical improvements with connectivity values. Across patients, connectivity values were correlated with tremor improvements, resulting in an “R-map” model of connectivity profile associated with maximal tremor response. R-maps of both cohorts were compared and combined to a map showing the agreement between R-maps of both cohorts. Results: Both R-maps showed positive associations to M1 and negative correlations to cerebellar regions, reflected in the agreement map. Connectivity to the agreement map was associated with tremor improvement, independently from underlying disease and target. Conclusion: Similar connectivity profiles were associated with optimal improvement of tremor following both STN-DBS for PD and VIM-DBS for ET. While recent connectivity network analyses for the entire UPDRS-III in PD patients revealed differences from networks in ET patients, our results suggest that a symptom-specific, common network for tremor exists across both ET and PD patients and that the network can be modulated at different target nodes.

338 Disparate Use of Deep Brain Stimulation for Parkinson’s Disease in Black Patients is Driven by Barriers to Access that Arise Before Surgical Referral

INTRODUCTION: Deep brain stimulation (DBS) is an effective therapy for Parkinson’s disease (PD) that can provide substantial improvements in quality of life for patients inadequately controlled with medication. However, there is severe racial disparity in its use, with Black PD patients being much less likely to be treated with DBS than White patients. We hypothesized that the extensive process of patient selection and workup limits access to DBS, and we analyzed the records of a major movement disorder and DBS center to determine if this barrier to access was apparent. METHODS: We reviewed a database that includes every patient considered for DBS between 2016 and February of 2021. We cross-tabulated the patients by race, as documented in the medical record, and progression to surgical intervention. We determined whether there was a significant difference in the proportion of patients who were not treated with DBS via Fisher’s exact test. RESULTS: Out of 211 PD patients evaluated by a DBS movement specialist and referred for preoperative workup since 2016, 10 (5%) were indicated to be Black, compared to 160 (76%) White, 7 (3%) Asian, and 34 (16%) Unknown. Of those, 7/10 (70%) Black patients were treated with surgery, compared to 123/160 (77%) White, 5/7 (71%) Asian, and 23/34 (68%) Unknown (p = 0.61, Fisher’s Exact Test). CONCLUSION: While very few Black patients were referred to DBS Clinic, there was no significant difference between racial groups in the likelihood of receiving surgery once referred. This suggests that the disparity arises before preoperative workup, with potential candidates for treatment never reaching DBS clinic. Future work should attempt to identify factors driving this disparity, with particular attention paid to referral patterns. Notably, these results do not exclude the possibility that the general burden of preoperative evaluation and postoperative management might influence decisions on whether to refer patients.

Necessity and feasibility of remote tele-programming of deep brain stimulation systems in Parkinson's disease

IntroductionOutcomes after deep brain stimulation (DBS) therapy are dependent on good surgical placement in the target nucleus and optimized stimulation parameters through multiple programming sessions. This often requires frequent travel to a specialized DBS center, which presents a challenge for those with limited access. Recently, the FDA approved a remote tele-programming solution for DBS. To determine if remote tele-programming of DBS systems is beneficial and useful for Parkinson's Disease (PD) patients, Parkinson's Foundation hosted a survey in collaboration with Abbott Labs. MethodsThe survey was conducted to assess the need for telemedicine among PD patients with DBS and the usability of the telehealth interface for DBS teleprogramming. The survey included two validated instruments: The Effective Accessibility and Accommodation survey (EAA) and the Telehealth Usability Questionnaire (TUQ). Results47 patients completed the EAA and 41 completed the TUQ. Results from the EAA revealed more than a third of PD patients cannot easily get to a clinic for various reasons, and more than a quarter reported difficulty contacting their clinic for advice. Results from the TUQ revealed overall satisfaction with the DBS remote programming telehealth interface and care provided. The majority of respondents reported that remote tele-programming visits are similar in quality to in-person visits. ConclusionThis study provides support for the use of telehealth and tele-programming for DBS management in PD patients. The ability to use remote technologies for care will increase access to DBS and mitigate the disparities that currently prevent access to care.

CLOVER-DBS: Algorithm-Guided Deep Brain Stimulation-Programming Based on External Sensor Feedback Evaluated in a Prospective, Randomized, Crossover, Double-Blind, Two-Center Study.

Recent technological advances in deep brain stimulation (DBS) (e.g., directional leads, multiple independent current sources) lead to increasing DBS-optimization burden. Techniques to streamline and facilitate programming could leverage these innovations. We evaluated clinical effectiveness of algorithm-guided DBS-programming based on wearable-sensor-feedback compared to standard-of-care DBS-settings in a prospective, randomized, crossover, double-blind study in two German DBS centers. For 23 Parkinson's disease patients with clinically effective DBS, new algorithm-guided DBS-settings were determined and compared to previously established standard-of-care DBS-settings using UPDRS-III and motion-sensor-assessment. Clinical and imaging data with lead-localizations were analyzed to evaluate characteristics of algorithm-derived programming compared to standard-of-care. Six different versions of the algorithm were evaluated during the study and 10 subjects programmed with uniform algorithm-version were analyzed as a subgroup. Algorithm-guided and standard-of-care DBS-settings effectively reduced motor symptoms compared to off-stimulation-state. UPDRS-III scores were reduced significantly more with standard-of-care settings as compared to algorithm-guided programming with heterogenous algorithm versions in the entire cohort. A subgroup with the latest algorithm version showed no significant differences in UPDRS-III achieved by the two programming-methods. Comparing active contacts in standard-of-care and algorithm-guided DBS-settings, contacts in the latter had larger location variability and were farther away from a literature-based optimal stimulation target. Algorithm-guided programming may be a reasonable approach to replace monopolar review, enable less trained health-professionals to achieve satisfactory DBS-programming results, or potentially reduce time needed for programming. Larger studies and further improvements of algorithm-guided programming are needed to confirm these results.

Risk of Infection after Deep Brain Stimulation Surgery with Externalization and Local-Field Potential Recordings: Twelve-Year Experience from a Single Institution

Introduction: Deep brain stimulation (DBS) has been an established surgical procedure in the field of functional neurosurgery for many years. The experimental electrophysiological method of local field potential (LFP) recordings in postsurgically externalized patients has made substantial contributions to the better understanding of pathophysiologies underlying movement disorders. As interest in LFP recordings for the development of improved stimulation strategies increases, this study’s aim was to provide evidence concerning safety of this research method, in a major DBS center. Methods: We retrospectively analyzed incidence and infection characteristics in adult patients who underwent two-staged DBS surgery with temporary externalization of leads in our center between January 2008 and November 2019. We focused on whether patients had participated in LFP recordings, and evaluated incidence of infections at 3 months and 1 year after the surgery based on medical records. Infection rates were compared to major DBS studies and reports focusing on the risk of infection due to externalization of DBS leads. Results were visualized using descriptive statistics. Results: Between January 2008 and November 2019, DBS surgery was performed in 528 patients (389/139 patients in the LFP/non-LFP group), mainly for movement disorders such as Parkinson’s disease (308), dystonia (93), and essential tremor (86). Of the patients, 72.9% participated in LFP recordings. The incidence of infections in the acute postsurgical phase (3 months) was 2.46% and did not differ significantly between the LFP group (1.8%) and the non-LFP group (4.32%). The overall incidence after 1 year amounted to 3.6% (19 patients) with no difference between LFP/non-LFP groups. Incidence rates reported in the literature show a large variety (2.6–10%), and the incidence reported here is within the lower range of reported incidences. Discussion/Conclusion: This study demonstrates that DBS is a surgical procedure with a low risk of infection in a large patient cohort. Importantly, it shows that LFP recordings do not have a significant effect on the incidence of infections in patients with externalization. With a representative cohort of more than 380 patients participating in LFP-recordings, this underlines LFP as a safe method in research and supports further use of this method, for example, for the development of adaptive stimulation protocols.

Targeting of the Subthalamic Nucleus in Patients with Parkinson's Disease Undergoing Deep Brain Stimulation Surgery.

Precise stereotactic targeting of the dorsolateral motor part of the subthalamic nucleus (STN) is paramount for maximizing clinical effectiveness and preventing side effects of deep brain stimulation (DBS) in patients with advanced Parkinson’s disease. With recent developments in magnetic resonance imaging (MRI) techniques, direct targeting of the dorsolateral part of the STN is now feasible, together with visualization of the motor fibers in the nearby internal capsule. However, clinically relevant discrepancies were reported when comparing STN borders on MRI to electrophysiological STN borders during microelectrode recordings (MER). Also, one should take into account the possibility of a 3D inaccuracy of up to 2 mm of the applied stereotactic technique. Pneumocephalus and image fusion errors may further increase implantation inaccuracy. Even when implantation has been successful, suboptimal lead anchoring on the skull may cause lead migration during follow-up. Meticulous pre- and intraoperative imaging is therefore indispensable, and so is postoperative imaging when the effects of DBS deteriorate during follow-up. Thus far, most DBS centers employ MRI targeting, multichannel MER, and awake test stimulation in STN surgery, but randomized trials comparing surgery under local versus general anesthesia and additional studies comparing MER-STN borders to high-field MRI-STN may change this clinical practice. Further developments in imaging protocols and improvements in image fusion processes are needed to optimize placement of DBS leads in the dorsolateral motor part of the STN in Parkinson’s disease.

Pulse Width and Implantable Pulse Generator Longevity in Pallidal Deep Brain Stimulation for Dystonia: A Population-Based Comparative Effectiveness Study

Introduction: A wide range of pulse widths (PWs) has been used in globus pallidus internus (GPi) deep brain stimulation (DBS) for dystonia. However, no specific PW has demonstrated clinical superiority, and the paradigm may differ among DBS centers. Objective: To investigate how different paradigms of PWs in GPi DBS for dystonia affect implantable pulse generator (IPG) longevities and energy consumption. Methods: Thirty-nine patients with dystonia treated with bilateral GPi DBS at 2 Swedish DBS centers from 2005 to 2015 were included. Different PW paradigms were used at the 2 centers, 60–90 µs (short PWs) and 450 µs (long PW), respectively. The frequency of IPG replacements, pulse effective voltage (PEV), IPG model, pre-/postoperative imaging, and clinical outcome based on the clinical global impression (CGI) scale were collected from the medical charts and compared between the 2 groups. Results: The average IPG longevity was extended for the short PWs (1,129 ± 50 days) compared to the long PW (925 ± 32 days; χ² = 12.31, p = 0.0005, log-rank test). IPG longevity correlated inversely with PEV (Pearson’s r = –0.667, p < 0.0001). IPG longevities did not differ between Kinetra® and Activa® PC in the short (p = 0.319) or long PW group (p = 0.858). Electrode distances to the central sensorimotor region of the GPi did not differ between the short or long PW groups (p = 0.595). Pre- and postoperative CGI did not differ between groups. Conclusions: Short PWs were associated with decreased energy consumption and increased IPG longevity. These effects were not dependent on the IPG model or the anatomic location of the electrodes. PWs did not correlate with symptom severities or clinical outcomes. The results suggest that the use of short PWs might be more energy efficient and could therefore be preferred initially when programming patients with GPi DBS for dystonia.

A unified connectomic target for deep brain stimulation in obsessive-compulsive disorder

Multiple surgical targets for treating obsessive-compulsive disorder with deep brain stimulation (DBS) have been proposed. However, different targets may modulate the same neural network responsible for clinical improvement. We analyzed data from four cohorts of patients (N = 50) that underwent DBS to the anterior limb of the internal capsule (ALIC), the nucleus accumbens or the subthalamic nucleus (STN). The same fiber bundle was associated with optimal clinical response in cohorts targeting either structure. This bundle connected frontal regions to the STN. When informing the tract target based on the first cohort, clinical improvements in the second could be significantly predicted, and vice versa. To further confirm results, clinical improvements in eight patients from a third center and six patients from a fourth center were significantly predicted based on their stimulation overlap with this tract. Our results show that connectivity-derived models may inform clinical improvements across DBS targets, surgeons and centers. The identified tract target is openly available in atlas form.

Deep brain stimulation: Imaging on a group level

Deep Brain Stimulation (DBS) is an established treatment option for movement disorders and is under investigation for treatment in a growing number of other brain diseases. It has been shown that exact electrode placement crucially affects the efficacy of DBS and this should be considered when investigating novel indications or DBS targets. To measure clinical improvement as a function of electrode placement, neuroscientific methodology and specialized software tools are needed. Such tools should have the goal to make electrode placement comparable across patients and DBS centers, and include statistical analysis options to validate and define optimal targets. Moreover, to allow for comparability across different centers, these need to be performed within an algorithmically and anatomically standardized and openly available group space. With the publication of Lead-DBS software in 2014, an open-source tool was introduced that allowed for precise electrode reconstructions based on pre- and postoperative neuroimaging data. Here, we introduce Lead Group, implemented within the Lead-DBS environment and specifically designed to meet aforementioned demands. In the present article, we showcase the various processing streams of Lead Group in a retrospective cohort of 51 patients suffering from Parkinson’s disease, who were implanted with DBS electrodes to the subthalamic nucleus (STN). Specifically, we demonstrate various ways to visualize placement of all electrodes in the group and map clinical improvement values to subcortical space. We do so by using active coordinates and volumes of tissue activated, showing converging evidence of an optimal DBS target in the dorsolateral STN. Second, we relate DBS outcome to the impact of each electrode on local structures by measuring overlap of stimulation volumes with the STN. Finally, we explore the software functions for connectomic mapping, which may be used to relate DBS outcomes to connectivity estimates with remote brain areas. The manuscript is accompanied by a walkthrough tutorial which allows users to reproduce all main results presented here. All data and code needed to reproduce results are openly available.

Deep brain stimulation in Parkinson's disease: A multicentric, long-term, observational pilot study

BackgroundThe impact of deep brain stimulation (DBS) on cognitive and urinary disorders, falls, and eventually hospitalizations and mortality in Parkinson's disease (PD) is still debated. ObjectiveWe compared the rates of dementia, mild cognitive impairment (MCI), urinary incontinence, nocturia, falls, hospitalizations, and mortality in a cohort of PD patients undergoing DBS with a cohort of medically-treated patients chosen as controls. MethodsWe conducted a retrospective pilot study in six Italian DBS centers. 91 PD patients receiving DBS and 91 age- and gender-matched controls receiving the best medical treatment alone with a minimum follow-up of one year were enrolled. Clinical data were collected from baseline to the last follow-up visit using an ad-hoc developed web-based system. ResultsThe risk of dementia was similar in the two groups while patients in the surgical cohort had lower rates of MCI, urinary incontinence, nocturia, and falls. In contrast, the risk of hospital admissions related to PD was higher in the surgical cohort. However, when excluding hospitalizations related to DBS surgery, the difference between the two cohorts was not significant. The surgical cohort had a lower number of hospitalizations not related to PD. The risk of death was similar in the two groups. ConclusionDespite a higher risk of hospitalization, patients receiving DBS had a lower rate of MCI, urinary incontinence, nocturia and falls, without evidence of an increased risk of dementia and mortality. Although these findings need to be confirmed in prospective studies, they seem to suggest that DBS may play a significant role in the management of non-motor symptoms and common complications of advanced PD.

Some Clinically Useful Information that Neuropsychology Provides Patients, Carepartners, Neurologists, and Neurosurgeons About Deep Brain Stimulation for Parkinson's Disease.

Deep brain stimulation (DBS) is an effective (but non-curative) treatment for some of the motor symptoms and treatment complications associated with dopaminergic agents in Parkinson's disease (PD). DBS can be done relatively safely and is associated with quality of life gains. In most DBS centers, neuropsychological evaluations are performed routinely before surgery, and sometimes after surgery. The purpose of such evaluation is not to decide solely on its results whether or not to offer DBS to a given candidate, but to provide the patient and treatment team with the best available information to make reasonable risk-benefit assessments. This review provides information relevant to the questions often asked by patients and their carepartners, neurologists, and neurosurgeons about neuropsychological outcomes of DBS, including neuropsychological adverse event rates, magnitude of cognitive changes, outcomes after unilateral versus bilateral surgery directed at various targets, impact of mild cognitive impairment (MCI) on outcome, factors implicated in neurobehavioral outcomes, and safety of newer interventions or techniques such as asleep surgery and current steering.

Deep brain stimulation and dystonia: About 10 new pediatric cases and a new DBS center in Paris

Objective: Deep Brain Stimulation (DBS) is a surgical technique used for dystonic patients during which a continuous electrical stimulation is delivered to the Globus Pallidum. Technical improvements render this procedure possible for young children. However, predictive factors for good responders remain poorly understood. We opened a new DBS pediatric center in 2015. We present our first results and the organization of our multidisciplinary care system. Methods: We report a series of 10 children seen in consultation for DBS during 2015–2016. In the absence of radiological or etiologic contraindications, the files are reviewed and the indications for implantation are validated in multidisciplinary consultation (neuropediatricians, neurologists, neurosurgeons, rehabilitation physicians). Once included, children are evaluated pre- and post-operatively by the “dystonia referents” team within the hospital (psychologist, physiotherapist, nurse, anesthetist, resuscitator, ENT, photographer for documentation of symptoms) conjointly with the neuropediatrician and neurosurgeon. Results: 5 children were implanted (2 DYT1 mutations, 1 PKAN, 1 severe dyskinetic dystonia, 1 generalized dystonia), 3 were finally excluded and 2 refused intervention. All implanted patients improved (video), between 30 to 95% (patient DYT1). The decreased dyskinesias has also uncovered learning abilities in the dyskinetic patient. Conclusion: DBS of the GPi has a well-known efficacy in DYT1, however recent studies as ours show that other primary or secondary dystonias may benefit as well from such interventions. Implantation in young children, however, poses a problem concerning the cumbersomeness long-term follow-up and need for regular re- interventions. The indications for implantation require in our opinion a multidisciplinary decision and to obtain the perfect adhesion of the family. A protocoled and rigorous follow-up of this population will improve both the selection criteria and suggest predictive parameters for better responders.

How to improve patient education on deep brain stimulation in Parkinson\u2019s disease: the CARE Monitor study

BackgroundThe introduction of deep brain stimulation (DBS) about 25 years ago provided one of the major breakthroughs in the treatment of Parkinson’s disease (PD). However, a high percentage of patients are reluctant to undergo DBS. Previous research revealed that the critical step on the patient’s path to DBS is the decision whether to undergo further diagnostic assessment for surgery at a specialized DBS-center. The aims of the current study were to evaluate how effective the combination of an outpatient DBS screening tool, STIMULUS, with specially developed educational material was to enhance patient education on DBS and to identify motivational aspects which influenced the patients’ willingness to undergo further assessment.MethodsIn total, 264 patients were identified as appropriate candidates for DBS by general neurologists using the electronic preselection tool STIMULUS. Patient-centered information material was designed and handed out to support education on DBS. Further, several clinical characteristics and details of the patient counseling were documented. Refusal or consent to show up at a DBS center was registered over the following 16 months.Results114 (43.2%) patients preselected as eligible for DBS (STIMULUS Score ≥ 6) agreed to show up at a specialized DBS center to undergo further diagnostic assessment. The patients’ ages, PD classification as an akinetic-rigid type and the talks’ topics side-effects of dopaminergic medication and the optimal time frame had a significant influence on the patients’ decisions.ConclusionsThe combination of preselection tools as STIMULUS with comprehensive information material is effective to increase DBS-acceptance rate in PD patients. Important topics of the information about DBS cover the optimal time frame for DBS surgery, the side-effects of dopaminergic medication as well as side-effects and complications of DBS surgery.

Surgical Replacement of Implantable Pulse Generators in Deep Brain Stimulation: Adverse Events and Risk Factors in a Multicenter Cohort

Background: Deep brain stimulation (DBS) is a growing treatment modality, and most DBS systems require replacement of the implantable pulse generator (IPG) every few years. The literature regarding the potential impact of adverse events of IPG replacement on the longevity of DBS treatments is rather scarce. Objective: To investigate the incidence of adverse events, including postoperative infections, associated with IPG replacements in a multicenter cohort. Methods: The medical records of 808 patients from one Australian and five Swedish DBS centers with a total of 1,293 IPG replacements were audited. A logistic regression model was used to ascertain the influence of possible predictors on the incidence of adverse events. Results: The overall incidence of major infections was 2.3% per procedure, 3.7% per patient and 1.7% per replaced IPG. For 28 of 30 patients this resulted in partial or complete DBS system removal. There was an increased risk of infection for males (OR 3.6, p = 0.026), and the risk of infection increased with the number of prior IPG replacements (OR 1.6, p < 0.005). Conclusions: The risk of postoperative infection with DBS IPG replacement increases with the number of previous procedures. There is a need to reduce the frequency of IPG replacements.

SP 7. How to address the poor treatment acceptance for deep brain stimulation in Parkinson’s disease

Question Deep Brain stimulation (DBS) is a widely established, effective and well-tolerated treatment for Parkinson’s disease (PD). The patients’ way to receive this treatment usually consists of two steps: first, general neurologists refer them to a specialized DBS center where they undergo further diagnostic assessment and the final decision for or against this treatment is made. Electronic tools are available to support general neurologists in the selection of DBS candidates. Nevertheless, even after being preselected as an appropriate candidate, the majority of patients refused to be referred to a DBS center (Wachter et al., J Neurol 2011;258:641–646). Patients and methods Two projects were initiated to increase the treatment acceptance of DBS for PD: (A) A collaboration of 20 general neurologists and two movement disorder specialists at the University Hospital Dusseldorf was established. (B) 51 general neurologists located all over Germany were trained to use the electronic preselection tool STIMULUS and were handed out newly developed information materials. In both projects, appropriate DBS candidates were preselected. Their acceptance or refusal to undergo further diagnostic assessment at a DBS center was documented within a 16 months follow-up period. Further, several clinical characteristics and details of the patient briefing were collected and analyzed to identify factors which were predictive for patients’ decisions. Results (A) 912 PD patients were examined by the movement disorder specialist together with the general neurologist. In 92 cases (10.1%), a referral to undergo further diagnostic assessment at the University Hospital Dusseldorf was recommended. Within 16 months, 69 (70.4%) of those patients showed up in the specialized DBS center. (B) 264 patients were identified as appropriate candidates for DBS, using the electronic preselection tool STIMULUS and 114 (43.2%) had accepted to be referred to a DBS center within a 16 month follow-up period. The patients’ decisions were significantly influenced by their age, their classification as an akinetic-rigid type and when mentioning a potential reduction of dopaminergic side effects as well as the optimal time frame for DBS during the clarification talk. Conclusion Consultation visits by movement disorder specialists in collaboration with general neurologists substantially improved the treatment acceptance of PD patients for DBS. A training of general neurologists in combination with adequate information material might be a low-cost and effective alternative option. Both findings indicate the importance of a clarification talk to be crucial in order to increase the treatment acceptance for DBS. This assumption is supported by the talks’ topics side effects of dopaminergic medication and optimal time frame which were significantly related to a higher rate of acceptance if mentioned.