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Director of Functional and Restorative Neurosurgery
- 1. Assistant Professor of Surgery Director, Functional and Restorative Neurosurgery University of Connecticut
- 9. (Benabid et al., 1991; Blond et al., 1992)
- 11. Personnel Interdisciplinary DBS Equipment Collabora>on SURGERY Space
- 12. Movement Disorder APRNs/ Neurologist PAs Neuropsychologist Neurosurgeon Pa9ent Neuro-‐ICU Staff Pa9ent Anesthesia Team Electrophysiologist Psychiatrist OR Staff
- 14. Extension Implantable Pulse Generator (IPG) DBS Lead Test Stimulator Clinician Programmer Pt Controller
- 16. Psychiatrist Neurologist Neurosurgeon
- 17. STAGE PROCEDURE MRI (Stereotac>c) Pt Evaluated by Neurology Pt Evaluated by Neurosurgery Pt Evaluated by Neuropsychology BASELINE/PRE-‐OP Surgical Pre-‐op Hold Medica>ons Target Selec>on Trajectory Planning CT Scan Stereotac>c frame placement Electrophysiology recording Electrode placement STAGE 1 (2 DAYS) 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
- 18. STAGE PROCEDURE IPG Surgery Test impedance Post-‐Op X-‐Ray STAGE 2 (14 DAYS) Ini>al IPG Programming Pt Discharged same day Wk 2: Post-‐Op visit with surgeon Wk 4: Post-‐Op with neurologist STAGE 3 (12 WEEKS) Wk 12: Post-‐Op visits Neurologist and surgeon Post-‐Op visits with neurologist STAGE 4 (>12 WEEKS) for op>miza>on of parameters EPG =External Pulse Generator IPG =Implantable Pulse Generator
- 20. 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 Mild to moderate bilateral involvement, some postural instability, 3 physically independent 4 Severe disability, able to stand and walk unassisted 5 Wheelchair-‐bound or bedridden except when assisted
- 21. Unified Parkinson’s Disease Ra>ng Scale (UPDRS) Scale Measurement UPDRS Item Assessment Range Score includes 0 (not affected) Bradykinesia • body bradykinesia and hypokinesia to 36 (most severely subscale • le_-‐ and right-‐hand finger taps, opening and closing of affected) hands, prona>on/supina>on of hands, and heel taps Score includes • ac>on tremor of right and le_ hands 0 (not affected) to Tremor subscale • res>ng tremor in the le_ and right hands and feet 32 (most severely affected) • res>ng tremor of the face, lips, and chin Score includes 0 (not affected) to Rigidity subscale • rigidity in the neck 20 (most severely affected) • rigidity in the le_ and right upper and lower extremi>es PIGD (postural Score includes 0 (not affected) to instability and gait • falling, freezing, ability to walk 20 (most severely affected) disorder) • gait, postural stability Representa>ve sample of key measurement items from the UPDRS scale Fahn et al., 1987
- 22. Cuny et al, 2002 Ulla et al, 2009
- 25. Thalamus STN SNr Sagieal Sec>on through the Thalamus
- 27. Tremor-‐ Vim Dystonia-‐ Vim or GPi Parkinson’s Disease-‐ STN Emerging targets: Subthalamic white maeer, Paralemniscal Radia>ons, and PPN
- 31. % Improvement 100 90 80 70 60 71% 50 54% 40 51% 50% 30 20 10 0 “On 6me” more than doubled Krack et al., NEJM, 2003
- 32. DBS OFF DBS ON
- 33. • >800 published articles on DBS in MDJs • Safety and efficacy demonstrated • Long-term benefits
- 34. • The most common movement disorder • Big impact on life: – Socially – Professionally – Emo>onally hep://www.total-‐diet.com/170-‐stress-‐at-‐work/
- 35. • 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
- 36. • 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)
- 39. (Saxena et al., 2002)
- 42. LF Responders = pa>ents with at least a 25% reduc>on in YBOCS at last follow-‐up
- 44. • 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
- 45. Caudate Caudate IC IC Putamen Putamen GP AcM
- 47. Dorsolateral Premotor Motor Orbital Medial Region where Subcaudate Tractotomy, Gamma Capsulotomy, and DBS Targets Overlap S. Haber
- 48. • 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
- 50. 46 YOF, post-partum end-stage depression of over 10 years, medication-refractory with over 74 Electroconvulsive shock (ECT) treatments
- 53. (Mayberg et al., Neuron, 2005)
- 54. 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 5 10 12 18 17 12 (acute s>mula>on) 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
- 56. Location of Study N Baseline Post-DBS stimulation Baseline 12 months Lozano et al., 2008 20 Cg25 HDRS17 24.4 ± 3.5 12.6 ± 6.3 Mood 11.9 ± 1.5 5.9 ± 3.7* 1.6 ± 1.9* Anxiety 3.8 ± 2.4 2.0 ± 1.3* Sleep 3.6 ± 2.0 3.0 ± 1.4* Somatic 4.9 ± 0.8 Baseline 1 week 1 month Jiménez et al., 2007 1 Inferior GAF 20 90 thalamic peduncle HDRS 33-42 3 8 BDI 38 16 11 Baseline 6 months Malone et al., 2009 15 VC/VS HDRS24 33.1 17.5 MADRS 34.8 17.9 Baseline 1 week Schaepfer et al., 2008 3 NAcc HDRS24 33.7 ± 3.8 19.7 ± 6.7 MADRS 35.7 ± 2.9 24.7 ± 6.7 HDRS , Hamilton Depression Rating Scale ; GAF, Global Assessment of Functioning; BDI, Beck Depression Inventory; 17 HDRS , Hamilton Depression Rating Scale; MADRS, Montgomery-Asberg Depression Rating Scale (Ward et al., 2010) 24
- 57. Baseline CBF PET All PT vs. NC CBF increase 3 mo Post- DBS Surgery CBF decrease 6 mo Post- DBS Surgery x = -4 y = +28 (Mayberg et al., Neuron, 2005)
- 59. • Chronic relapsing disease • Psychological dependence • Physical dependence • Withdrawal syndrome • Tolerance • Con>nued use despite adverse consequences • Impaired control (Na6onal Survey on Drug use and Health, 2002) (The United Na6ons World Drug Report, 2007) (Diagnos6c and Sta6s6cal Manual of Mental Disorders, 4th Ed) (Interna6onal Classifica6on of Diseases, 10th Ed)
- 60. (Stelten et al., 2008)
- 61. (Gao et al., 2003)
- 62. • 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)