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Deep Brain Stimulation Management
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Book description

Deep Brain Stimulation Management is a practical guide to the use of this paradigm-shifting therapy for movement disorders, including Parkinson's disease, essential tremor, and dystonia. This title is an essential resource for clinicians who wish to begin utilizing DBS, as well as current practitioners seeking to improve their understanding and application of the technique. Highly illustrated and in full color throughout, this comprehensive book covers the key aspects of DBS practice, including patient selection, device programming and activation to achieve optimum symptom control, long-term management, and troubleshooting. With contributions from some of the most experienced clinical leaders in the field of DBS and extremely practical content, this is an essential reference text for any clinician working with DBS patients.

Reviews

'I recommend this textbook, which is, to my knowledge, the first of its kind to provide a practical guide to the clinical management of movement disorders in patients with implanted neurostimulators. The book will make a useful addition to the libraries of specialists in movement disorders and general neurologists, and help to train residents and nurses in this specialty.'

Jens Volkmann Source: The Lancet

'… will be a very practical guide and resource for providers who treat patients with deep brain stimulation. The paper quality and colorful illustrations are first rate. The breakout boxes throughout the chapters that summarize the take-home points are reader friendly and very helpful for quick scanning.'

Source: Doody's Notes

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Contents


Page 1 of 2


  • Chapter 6 - Managing essential tremor patients treated with deep brain stimulation
    pp 56-61
  • View abstract

    Summary

    This introductory chapter gives a brief overview of the book Deep Brain Stimulation Management, touching on the key topics pertaining to use of deep brain stimulation (DBS) for clinicians. DBS has evolved as an important and established treatment for movement disorders, and new indications for DBS in the treatment of neurological and psychiatric disorders are emerging. It uses a device with three implantable components: quadripolar brain lead(s), neurostimulator(s), and extension wire(s). There are three major movement disorders for which DBS is indicated: essential tremor, Parkinson's disease, and dystonia. DBS is a chronic neuromodulation therapy and not a surgical treatment. The chapter also gives an overview of how other chapters in this book are organized. This book serves as a practical reference, a "go to" guide to be kept in the clinic and consulted in the course of managing patients being considered for or treated with DBS.
  • Chapter 7 - Managing Parkinson's disease patients treated with deep brain stimulation
    pp 62-82
  • View abstract

    Summary

    This chapter details factors that should be considered when evaluating each patient's candidacy for deep brain stimulation (DBS). A number of factors need to be assessed in a systematic matter to determine each patient's candidacy for treatment with DBS. Parkinson's disease (PD) patients referred for surgery are at greater risk for psychotic symptoms, as they usually have relatively advanced disease. When considering a patient with essential tremor (ET) for DBS, it is important to make sure the patient meets clinical criteria for the diagnosis of ET as a first step. Determining which dystonia patients are candidates for DBS can be challenging than making this determination for patients with PD or ET. An effective method for arriving at decisions regarding the candidacy of patients for treatment with DBS is to collect the required data for each patient and then convene a conference. These details are discussed by the interdisciplinary/multidisciplinary team.
  • Chapter 8 - Managing dystonia patients treated with deep brain stimulation
    pp 83-90
  • View abstract

    Summary

    This chapter focuses on the second critical factor for success of deep brain stimulation (DBS), namely the placement of the DBS lead. DBS implantation is a team-based neurosurgical procedure, led by a neurosurgeon who should be trained in functional, stereotactic neurosurgery. Intraoperative microelectrode recording (MER) does not cause morbidity but improves bradykinesia before placement of the DBS lead. Once the DBS lead has been placed at the target depth, intraoperative macro-stimulation using the DBS lead is performed to test for optimal placement. The goal of intraoperative DBS test stimulation is to assess the efficacy of placement and the therapeutic window of stimulation. A map should be made of the position of the DBS lead in the nucleus of choice, as this helps the clinician who ultimately performs the programming of the DBS system. Poor placement can result from lack of use of intraoperative physiological mapping techniques.
  • Chapter 9 - Assessing patient outcome and troubleshooting deep brain stimulation
    pp 91-130
  • View abstract

    Summary

    This chapter introduces electrophysiological and electrical principles that underlie deep brain stimulation (DBS), with the purpose of facilitating effective and efficient postoperative programming. In order to comprehensively explore the effects of DBS, the entire set of electrode configurations and stimulation parameters would have to be systematically tested. There is considerable evidence that DBS-related changes in neurotransmitters and neuromodulators are unlikely to fully explain the DBS mechanisms of action. The control of the stimulating current is quite different in constant-current versus constant-voltage devices. The electrical charge generated during the DBS pulse dissipates with distance from the electrode. The stimulation parameters and electrode configurations can be used to control the spatial extent and number of axons excited by the DBS pulse. Excessive stimulation can lead to tissue damage by several mechanisms. In addition, unbalanced charges can create other reactive chemical species that can cause tissue damage.
  • Chapter 10 - Implementing deep brain stimulation into practice
    pp 131-140
  • View abstract

    Summary

    This chapter serves as a brief guide for clinicians taking care of patients with implanted deep brain stimulation (DBS) systems. It describes the different hardware components of available DBS systems that are relevant to the programmer. In order to understand the fundamentals of programming, it is important to be familiar with the devices used for DBS. In order to optimize the effects of DBS by providing maximal symptom suppression without unacceptable stimulation-induced adverse effects, clinicians can modify the electrode configuration and the electrical parameters used to deliver stimulation. Most centers wait 3-4 weeks after implantation of the DBS leads to initiate stimulation. Record keeping is an essential aspect of DBS programming, and most clinicians use dedicated forms to organize their programming data. At the end of each programming session, the clinician will document the final stimulation parameters and therapy measurements.
  • Appendix A: - Motor diary
    pp 141-141
  • View abstract

    Summary

    This chapter discusses the evaluation for and management of Vim deep brain stimulation (DBS) in the essential tremor (ET) patient. It is important to document the tasks that are of particular importance to the patient, such as writing, and putting on make-up. The majority of DBS clinicians initiate programming two to four weeks after Vim DBS lead implantation. Prior to initiating DBS programming, electrode impedance measurements should be performed to confirm integrity of the DBS system and its connections, and also to document a baseline measurement for future reference during troubleshooting. Stimulation-related adverse effects for DBS in the region of the Vim include paresthesia, dysarthria, incoordination, pain, asthenia, abnormal thinking, and headache. Often, stimulation parameters remain remarkably stable over time and provide excellent tremor suppression for many years. The neurostimulator can be turned off by the patient using the patient programmer.
  • Appendix B: - Unified Parkinson's Disease Rating Scale
    pp 142-146
  • View abstract

    Summary

    The practical matter of programming deep brain stimulation (DBS) settings in Parkinson's disease (PD) patients with DBS leads implanted in the globus pallidus internus (GPi), subthalamic nucleus (STN), or pedunculopontine nucleus (PPN) is more complex than thalamic ventral intermedius (Vim) DBS for tremor. Parkinson's disease-associated camptocormia is characterized by marked flexion of the trunk and often responds poorly to pharmacological treatment. This chapter discusses the specific issues pertaining to programming DBS devices in PD patients. In patients with PD and levodopa-induced dyskinesia, spread of stimulation current beyond the Vim to the CM/Pf or Voa/Vop regions of the thalamus may block dyskinesia. In the first two to three months postoperatively, the effects of STN stimulation may seem to wane as the micro-lesion effect associated with surgery diminishes. Understanding and managing the interaction of stimulation and pharmacological therapy is especially important in patients with PD.
  • Appendix C: - Abnormal Involuntary Movement Scale
    pp 147-148
  • View abstract

    Summary

    This chapter reviews the elements of anatomy that are required in order to understand and control deep brain stimulation (DBS) outcomes and side effects in patients with dystonia. The essential features for optimal programming in dystonia are: optimal electrode selection and configuration, amplitude, pulse width, and rate. One of the challenges of the initial programming in patients with dystonia is the virtual absence of immediate clinical response to stimulation. One of the very first reports describing successful treatment of dystonia with globus pallidus internal (GPi) DBS described maximal symptomatic relief with stimulation at 50 Hz, though at a very high pulse width. Appropriate DBS lead location is absolutely necessary to achieve optimal results. Currently available neurostimulators provide features that may help the programmer in distinguishing device-related problems from other forms of therapeutic failure. Current spread ventrally to the optic tract causes phosphenes and occasionally nausea.
  • Appendix D: - PDQ-39 questionnaire
    pp 149-150
  • View abstract

    Summary

    This chapter reviews methods of assessing outcomes following deep brain stimulation (DBS) and the approach to troubleshooting problems with DBS that may be responsible for poorer than expected outcomes. Assessment of outcome after DBS includes measurement of: impairment; disability; health-related quality of life (HRQL); and quality of life (QOL). A neuropsychological and neuropsychiatric examination should be performed in DBS candidates to identify problems and predisposing factors. An important concept in the evaluation and assessment of DBS patients is to utilize a multidisciplinary, or team, approach. Assessment and management of surgery-related issues and complications can be challenging in the acute time following DBS implantation surgery. Assessment of patients for DBS candidacy is best performed using a multidisciplinary team approach. Problems encountered with DBS surgery can be divided into four main categories: surgery-related; device-related; stimulation-related; and other issues, including disease progression, and poor DBS candidate/lack of the multidisciplinary team evaluation.
  • Appendix E: - Montreal Cognitive Assessment Test – English
    pp 151-151
  • View abstract

    Summary

    This chapter considers how a neurologist specializing in movement disorders should assemble a team and organize a standard protocol for accomplishing the necessary procedures. The deep brain stimulation (DBS) evaluation protocol is more complex for Parkinson's disease (PD) compared to essential tremor (ET) and dystonia, so most of the discussion in the chapter is focused on PD. The chapter discusses the general roles of the team members and details of the patient selection process. A psychologist provides psychological monitoring and mental healthcare to patients. Most often, a patient is referred from a neurologist who has cared for the patient for several years, when that neurologist thinks the patient might be helped by DBS. The medical evaluation is ordinarily performed by the primary care physician treating the patient. The clinicians involved need additional training, so that they can develop an understanding of the details of the selection process and programming techniques.

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