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Hospital Central de Asturias Centro Universitario

Hospital Central de Asturias Centro Universitario Unidad Multidisciplinar de los Trastornos del Movimiento. Scalp evoked potentials induced by Therapeutic DBS of Subthalamic nucleus F. Fernández-González , F. Seijo, C. Vallés, B. Lozano, L. Guisasola, C. Salvador, A. Galindo.

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Hospital Central de Asturias Centro Universitario

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  1. Hospital Central de Asturias Centro Universitario Unidad Multidisciplinar de los Trastornos del Movimiento • Scalp evoked potentials induced by • Therapeutic DBS of Subthalamic nucleusF. Fernández-González, F. Seijo, C. Vallés, • B. Lozano, L. Guisasola, C. Salvador, A. Galindo

  2. Scalp evoked potentials -Fpz+Fz -Fz+Cz -Cz-+Pz -Pz+Oz 50 ms R L Therapeutic DBS-STN stimulation

  3. Hospital Central de Asturias Centro Universitario Movement Disorders Multidisciplinary Team DBS - STN 1998 1999 2000 2001 2002 Total implants Bilateral 3 4 12 25 11 90 Unilateral 6 0 6 5 2 19 Total patients 9 4 18 30 13+ TOTAL 9 13 31 61 74+ 109

  4. N= 32mA mS Hz pole mean2.9 75.0 156.5 1.9 s.d.0.6 20.4 25.6 0.7 min. 1.0 60.0 130.0 0.0 1th quar. 2.5 60.0 135.0 2.0 median2.9 60.0 135.0 2.0 3th quar. 3.2 90.0 185.0 2.0 max. 4.0 120.0 185.0 3.0 Pre - STN DBS OFF medication Good Indication Post - STN DBS ON DBS - OFF Medication Bad results? 6 months

  5. METHODOLOGY 0.3 a 0.4 mm 1.0 mm 0.1 a 0.2 mm

  6. Unitary Recording G1 G2 Monopolar G2 recording Trigger threshold From STN we can record neurons with single and bursting pattern, From rostro-dorso-lateral Subthalamus we can record kinestethic unitary activities (32%). The kinesthetic neurons are somatotopically organized.

  7. Multiunitary Recording G1 G2 - 2 mm from AC-PC plane -3 mm from AC-PC plane -4 mm from AC-PC plane 1 Second - 5 mm from AC-PC plane From rostro-dorso-lateral STN we can record a kinesthetic related multiunitary activity with a 4Hz pattern ( - 3 mm AC-PCplane) Bipolar G1-G2 recording , descending 1 mm into the STN, the multiunitary recording show different values ( an irregular pattern at 7-9 Hz)

  8. Multiunitary Recording G1 G2 - 2 mm from AC-PC plane -3 mm from AC-PC plane 1 Second -4 mm from AC-PC plane - 5 mm from AC-PC plane Right Hemisphere Left Hemisphere Bipolar G1-G2 recording From Cortex (Cx) to Substantia Nigra pars reticulata (SNr) two seconds of multiunitary neuronal activity (bipolar recording) are recorded and stored in steps of 1 mm of the recording track, starting at cortex. From the 2 sec. recording of multiunitary neuronal activity the on line process calculates the integral of the multiunitary one, and is plotted against the distance to the target in a graphic that shows the stereotactic angle of the electrode trajectory in the sagital plane. Cx STR CI STN SNr

  9. Therapeutic tetraelectrode G1 G2 Intracerebral To the Electromyograph Extracraneal 7.5 mm

  10. Tetraelectrode Stimulation Tremor DisKinesias Rigidity Video 3 Video 1 Video 2

  11. 0 2.5 5.0 7.5 10.0 12.5 15.0 17.5 20.0 22.5 25.0 27.5 30.0 32.5 35.0 Fp. 3 (-3 IPC) AC-PC Plane 10.0 7.5 5.0 2.5 0.0 -2.5 -5.0 -7.5 -10.0 -12.5 -15.0 -17.5 -20.0 10.0 7.5 5.0 2.5 0.0 -2.5 -5.0 -7.5 -10.0 -12.5 -15.0 -17.5 -20.0 Stimulus: 2mA, 100 msec Current density = 0.02 mA/mm 2 2.5 mm Stimulus: 5mA, 100 msec Current density = 0.01 mA/mm 2 5.0 mm 0 2.5 5.0 7.5 10.0 12.5 15.0 17.5 20.0 22.5 25.0 27.5 30.0 32.5 35.0 Simulation of the electrical current diffusion by DBS monopolar stimulus. Is necesary a CD = 0.04 mA/mm2 to excite large axons and a CD = 0.3 mA/mm2 to excite small ones.

  12. ( x mA; 100 mS; 3 p.p.s) 1.7mA 1.9mA 2.1mA 2.3mA 2.5mA Subthreshol 2.9mA 3.4mA 3.8mA Motor threshold 4.1mA 4.3mA 4.4mA 4.5mA 4.6mA Motor response 4.7mA 4.9mA 5.0mA 0 1 2 3 Threshold to evoke motor responses (Sporadic motor responses) pole mean mA 3.0 3.5 4.3 5.3 s.d. 1.2 1.2 1.6 1.8 Motor evoked potential (Direct motor responses) pole mean mA 4.9 5.6 6.6 7.6 s.d. 1.8 1.6 1.7 1.8 60mV 0 1 2 3 -40 -20 0.0 +20 +40 +60 +80 +100 +120 +140ms 58.8ms 0 1 2 3 12.6ms Stimulation: DBS monopolar - 2 pole Recording: Ext. Dig. Communi’s rectified EMG Data from 64 implants

  13. Set A ( N = 18) Set B ( N = 14) Mean differences Set A versus Set B Stimulus intensity needed to induce Motor threshold 3.7 4.1 4.9 5.9 1.1 0.9 1.6 1.5 Therapeutic DBS parameters mA mS Hz Pole 3.1 82.1 166.1 1.7 0.4 30.4 26.4 0.7 Stimulus intensity needed to induce Motor threshold 2.0 2.5 3.4 4.3 0.5 0.7 1.0 1.7 Therapeutic DBS parameters mA mS Hz Pole 2.7 58.8 143.3 1.9 0.6 14.3 20.3 0.6 <0.001 <0.001 <0.001 <0.001 Therapeutic DBS parameters mA mS Hz Pole <0.05 <0.001 <0.01 >0.05 Mean S.D. Mean S.D. Mean S.D. Mean S.D. p p N = 18 Set A : < 2.5 mA N = 14 Set B : > 2.5 mA TOTAL Patients Number = 32 Median values = 5.0 3.8 3.0 2.5 mA Stimulus intensity needed to induce Motor threshold on Ext.Dig.Comm. x mA 100 mS 3 pps - 0.9 0.7 0.5 0.9 - 0.7 0.6 0.7 0.7 - 0.9 0.5 0.6 0.9 - Linear correlation (Motor threshold) TOTAL Number = 32

  14. 0 1 2 3 S.I. 10-20 Fpz Fz -Fpz+Fz Fp2 F4 Cz -Fz+Cz C4 -Cz-+Pz Pz P4 Oz -Pz+Oz 100 ms 5.5 ms -Fpz+Fz 7 a 12 ms 75 ms -Fpz+Fz -Fz+Cz -Cz-+Pz 50 ms 40uV -Pz+Oz 25 ms

  15. 5.5ms 7 a 12 ms 75ms 0 1 2 3 -Fpz+Fz 40 mV Stim. 25 ms 60mV 13.2 mSec Ext. Dig. Comm. 8.4 mSec Borla mentonniana 5.3 mSec Masseter Are this cortical recorded components EMG artefacts? 1.7mA 1.9mA 2.1mA 2.3mA 2.5mA Subthreshol 2.9mA 3.4mA 3.8mA Motor threshold 4.1mA 4.3mA 4.4mA 4.5mA 4.6mA Motor response 4.7mA 4.9mA 5.0mA STN monopolar stimulation -40 -20 0.0 +20 +40 +60 +80 +100 +120 +140ms 58.8ms 12.6ms Stimulation: DBS monopolar - 2 pole Recording: Ext. Dig. Communi’s rectified EMG

  16. S.I. 10-20 N= 32mA mS Hz pole mean2.9 75.0 156.5 1.9 s.d.0.6 20.4 25.6 0.7 Fpz Fz Fp2 F4 Cz C4 Pz P4 Oz NO motor responses NO motor responses Sporadic motor responses Direct motor responses Fpz - Fz Fz - Cz Cz - Pz Pz - Oz Fpz - Fz Fz - Cz Cz - Pz Pz - Oz Fpz - Fz Fz - Cz Cz - Pz Pz - Oz 40uV 20 ms NO scalp responses Scalp evoked responses Scalp evoked responses 0 1 2 3 Remember: therapeutic values STIMULATION: Monopolar DBS-STN Tetraelectrode: 2 Subminimal 0.6 mA RECORDING: A) Ext.Dig.Comm. Integrated EMG B) Scalp evoked potentials Subthreshold 2.3 mA Motor threshold 4.6 mA Mínimal 1.1 mA

  17. S.I. 10-20 Fpz Fz Fp2 +2 F4 Cz +4 C4 +0 Pz P4 +6 Trajectory 20 ms Oz -2 Target Stimulation: Bipolar 500 mA; 100 ms 0.3 a 0.4 mm 1.0 mm -4 -6 0.1 a 0.2 mm

  18. 2 a 3 m 2 a 3 m 2 a 3 m 2 a 3 m Zona Incerta Subthalamic nucleus Cerebral peduncule Ramón y Cajal (1906) Capsula interna (2 a 3 m) Lenticular fasciculus or Forel’s field H2) (2 a 3 m) Subthalamic fasciculus (2 a 3 m) Ansa lenticilaris, Thalamic fasciculus or Forel’ H1. (2 a 3 m) Based in Parent (1998)

  19. Hospital Central de Asturias Centro Universitario Unidad Multidisciplinar de los Trastornos del Movimiento

  20. S.I. 10-20 Fpz Fz Fp2 F4 Cz C4 Pz P4 40uV Oz 20ms Umbral motor Ejemplo mapping: N. Mediano dcho. Mapping de la activación cortical inducida por el estimulo umbral motor (3.5 mA) del núcleo Subtalámico derecho, aplicado como estimulación bipolar con cátodo en el polo 2 del tetraelectrodo implantado

  21. S.I. 10-20 Fpz Fz Fp2 F4 Cz C4 Pz P4 Oz Ejemplo mapping por estimulación a nivel del núcleo Subtalámico Izdo, por estimulo bipolar con cátodo en el polo 2 del tetraelectrodo implantado Ejemplo mapping: Estimulo n. Subtalámico izquierdo Ejemplo mapping: Estimulo N. Mediano derecho 0 a 40 ms 252 a 292 ms 336 a 502 ms

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