Error reduction with routine checklist use during deep brain stimulation surgery.

Background: The use of checklists to reduce error rates in procedural literature has led our group to employ this strategy during deep brain stimulation (DBS) surgery.

Objectives: We sought to examine the improvement in the number of errors made during DBS surgery after long-term use of a checklist.

Methods: Our checklist has been used for all DBS cases at our institution since the beginning of this study's enrollment in 2008.

Implications for programming strategy of the location of the active contact in subthalamic nucleus deep brain stimulation.

We aimed to determine whether our targeting method for the subthalamic nucleus (STN) in Parkinson's disease informs the initial programming sequence. We evaluated 100 STN-lead pairs from 50 patients who underwent bilateral STN-deep brain stimulation operations. All patients had at least one year of follow-up.

Neuronal activity in the human subthalamic nucleus encodes decision conflict during action selection.

The subthalamic nucleus (STN), which receives excitatory inputs from the cortex and has direct connections with the inhibitory pathways of the basal ganglia, is well positioned to efficiently mediate action selection. Here, we use microelectrode recordings captured during deep brain stimulation surgery as participants engage in a decision task to examine the role of the human STN in action selection. We demonstrate that spiking activity in the STN increases when participants engage in a decision and that the level of spiking activity increases with the degree of decision conflict.

Depth-time interpolation of feature trends extracted from mobile microelectrode data with kernel functions.

Background/aims: Microelectrode recording (MER) is necessary for precision localization of target structures such as the subthalamic nucleus during deep brain stimulation (DBS) surgery. Attempts to automate this process have produced quantitative temporal trends (feature activity vs. time) extracted from mobile MER data.

The effect of intraventricular trajectory on brain shift in deep brain stimulation.

Background: Brain shift during deep brain stimulation (DBS) surgery may compromise target localization. Loss of cerebrospinal fluid is believed to be the underlying mechanism, thus an intraventricular trajectory during DBS surgery may be associated with increased shift, in addition to other complications, such as intraventricular hemorrhage.

Objective: We set out to assess the effect of traversing the lateral ventricle on brain shift during DBS surgery.

Expanding applications of deep brain stimulation: a potential therapeutic role in obesity and addiction management.

Background: The indications for deep brain stimulation (DBS) are expanding, and the feasibility and efficacy of this surgical procedure in various neurologic and neuropsychiatric disorders continue to be tested. This review attempts to provide background and rationale for applying this therapeutic option to obesity and addiction. We review neural targets currently under clinical investigation for DBS—the hypothalamus and nucleus accumbens—in conditions such as cluster headache and obsessive-compulsive disorder.

Self-administered preoperative antiseptic wash to prevent postoperative infection after deep brain stimulation.

Background: Prevention of surgical site infections is critical in deep brain stimulation (DBS). In the present study, we tested the ability of a self-administered preoperative alcohol-based (70% ethyl alcohol) preparation to reduce the rate of postoperative infection after DBS surgery.

Methods: This Institutional Review Board-approved retrospective review was conducted at our institution between January 2005 and October 2007 (mean follow-up, 23 months).

Longevity analysis of currently available deep brain stimulation devices.

Objective: There continues to be debate about the surgical technique, electrophysiology, and hardware used in deep brain stimulation (DBS), despite its widespread use in medically intractable Parkinson's disease and essential tremor. This article is the first, to our knowledge, to compare the longevity of the available internal pulse generators (IPGs) of DBS (Kinetra and Soletra, Medtronics).

Methods: We compared the elapsed time from the initial surgery to the first replacement of IPGs in patients with bilateral Soletra IPGs to those with the unilateral Kinetra IPG and analyzed the various stimulation parameters of each device.

Best surgical practices: a stepwise approach to the University of Pennsylvania deep brain stimulation protocol.

Deep brain stimulation (DBS) is the treatment of choice for otherwise healthy patients with advanced Parkinson disease who are suffering from disabling dyskinesias and motor fluctuations related to dopaminergic therapy. As DBS is an elective procedure, it is essential to minimize the risk of morbidity. Further, precision in targeting deep brain structures is critical to optimize efficacy in controlling motor features.

Deep brain stimulation in the treatment of refractory epilepsy: update on current data and future directions.

Deep brain stimulation for epilepsy has garnered attention from epileptologists due to its well-documented success in treating movement disorders and the low morbidity associated with the implantation of electrodes. Given the large proportion of patients who fail medical therapy and are not candidates for surgical amelioration, as well as the suboptimal seizure control offered by vagus nerve stimulation, the search for appropriate brain structures to serve as targets for deep brain stimulation has generated a useful body of evidence to serve as the basis for larger investigations. Early results of the SANTE trial should lay the foundation for widespread implementation of DBS for epilepsy targeting the anterior thalamic nucleus.

Subcutaneous heparin for prophylaxis of venous thromboembolism in deep brain stimulation surgery: evidence from a decision analysis.

Objective: The addition of subcutaneous heparin (SQH) to mechanical prophylaxis for venous thromboembolism (VTE) involves a balance between the benefit of greater protection from VTE and the added risk of intracranial hemorrhage. There is evidence that the hemorrhage risk outweighs the benefits for patients undergoing craniotomy. We investigated the safety of SQH in patients undergoing deep brain stimulation (DBS) surgery.

Human substantia nigra neurons encode unexpected financial rewards.

The brain's sensitivity to unexpected outcomes plays a fundamental role in an organism's ability to adapt and learn new behaviors. Emerging research suggests that midbrain dopaminergic neurons encode these unexpected outcomes. We used microelectrode recordings during deep brain stimulation surgery to study neuronal activity in the human substantia nigra (SN) while patients with Parkinson's disease engaged in a probabilistic learning task motivated by virtual financial rewards.

Thalamic deep brain stimulation for midbrain tremor secondary to cystic degeneration of the brainstem.

Objective: Tremor resulting from damage to midbrain structures is poorly understood and often difficult to treat. The authors report a case of cystic degeneration of the brainstem with resultant Holmes-like tremor which was successfully treated using a stimulating electrode placed in the contralateral ventralis intermedius nucleus (VIM) of the thalamus.

Clinical Presentation: A 31-year-old man presented with a multilobulated, multiseptated lesion of the upper brainstem diagnosed after subacute onset of headaches.

Feasibility of an operational standardized checklist for movement disorder surgery. A pilot study.

Despite the clinical success of deep brain stimulation (DBS), it remains to be elucidated where within the work process the surgical result could diverge from the surgical plan. We sought to determine this. We implemented a standardized checklist to detect and remediate procedural errors.

Deep brain stimulation in the treatment of obesity.

Obesity is a growing global health problem frequently intractable to current treatment options. Recent evidence suggests that deep brain stimulation (DBS) may be effective and safe in the management of various, refractory neuropsychiatric disorders, including obesity. The authors review the literature implicating various neural regions in the pathophysiology of obesity, as well as the evidence supporting these regions as targets for DBS, in order to explore the therapeutic promise of DBS in obesity.

Use of an integrated platform system in the placement of deep brain stimulators.

The placement of deep brain stimulator leads requires a great deal of technology and equipment. We describe our 25-month experience with an integrated platform system, the StimPilot (Medtronic Inc., Minneapolis, MN), for the placement of deep brain stimulator leads.

Determination of subthalamic nucleus location by quantitative analysis of despiked background neural activity from microelectrode recordings obtained during deep brain stimulation surgery.

Microelectrode recording during deep brain stimulation surgery is a useful adjunct for subthalamic nucleus (STN) localization. We hypothesize that information in the nonspike background activity can help identify STN boundaries. We present results from a novel quantitative analysis that accomplishes this goal.

Deep brain stimulation for epilepsy.

Many patients who suffer from medically refractory epilepsy are not candidates for resective brain surgery. Success of deep brain stimulation (DBS) in relieving a significant number of symptoms of various movement disorders paved the way for investigations into this modality for epilepsy. Open-label and small blinded trials have provided promising evidence for the use of DBS in refractory seizures, and the first randomized control trial of DBS of the anterior thalamic nucleus is currently underway.

Brain shift during deep brain stimulation surgery for Parkinson's disease.

Background: Brain shift may occur during deep brain stimulation (DBS) surgery, which may affect the position of subcortical structures, compromising target localization.

Methods: We retrospectively evaluated pre- and postoperative magnetic resonance imaging in 50 Parkinson's disease patients who underwent bilateral subthalamic nucleus (STN) DBS. Patients were separated into two groups: group A - those with <2 mm cortical displacement (66 leads) and group B - those with >or=2 mm cortical displacement (34 leads).

Subthalamic nucleus deep brain stimulation for severe idiopathic dystonia: impact on severity, neuropsychological status, and quality of life.

Object: Medically refractory dystonia has recently been treated using deep brain stimulation (DBS) targeting the globus pallidus internus (GPI). Outcomes have varied depending on the features of the dystonia. There has been limited literature regarding outcomes for refractory dystonia following DBS of the subthalamic nucleus (STN).

Implementation of dual simultaneous microelectrode recording systems during deep brain stimulation surgery for Parkinson's disease: technical note.

Objective: Microelectrode recording during deep brain stimulation surgery improves the likelihood of successful target localization and enables the electrophysiological characterization of human neural structures. Many clinical recording systems do not support the ability to capture research-quality recordings. Established clinical centers already using such equipment may be prevented from acquiring human intracranial data because of the need to completely change recording systems to obtain research-quality recordings.

Long-term outcomes of bilateral subthalamic nucleus stimulation in patients with advanced Parkinson's disease.

Background: In patients with advanced Parkinson's disease (PD), deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been shown to improve motor function and decrease medication requirements in the short term. However, the long-term benefits of DBS are not yet established.

Objective: It was the aim of this study to evaluate long-term outcomes of patients with PD treated with bilateral DBS of the STN.

Conventional MRI is inadequate to delineate the relationship between the red nucleus and subthalamic nucleus in Parkinson's disease.

Background: An understanding of the relationships between the anterior commissure-posterior commissure line (AC-PC), the subthalamic nucleus (STN), and red nucleus (RN) is imperative if these structures are to be used for targeting in deep brain stimulation. Currently, these relationships are incompletely understood and difficult to assess using conventional MRI. We examined the location and relationships of the STN and the RN to the AC-PC line and to each other in order to provide a greater understanding of their utility when targeting the STN, and the consistency of these anatomic relationships when examined using conventional MRI.

Long-term effects of bilateral subthalamic nucleus stimulation on health-related quality of life in advanced Parkinson's disease.

We evaluated the long-term effects of subthalamic nucleus (STN) stimulation on health-related quality of life (HRQL) in patients with advanced Parkinson's disease (PD). STN stimulation improves motor function and decreases medication requirements in patients with advanced PD. The impact of STN stimulation on HRQL is less well established, especially beyond 1 year after surgery.