P A C I F I C N E U R O . O R G

Deep Brain Stimulation: Current Indications and Future Directions

Jean-Philippe Langevin, MDDirector, Restorative Neurosurgery

Pacific Neuroscience Institute

Objectives

• Deep Brain Stimulation (DBS)

• Current and emerging indications for DBS

• Closed-loop DBS (epilepsy)

• Surgical technique and frameless DBS

Electrical stimulation of a specific region of the brain

St-Jude medical

Medtronic DBS Implant

St. Jude Medical DBS implant

Directional Stimulation

Future of Current Steering

Dijk KJ et al. J Neural Eng 2015;12 (4)

Neurology

• Parkinson’s Disease• Essential Tremor• Dystonia• Epilepsy (Neuropace)

Psychiatry

• Obsessive-Compulsive Disorder (HDE)

• Depression • Addiction • PTSD

Current and Emerging Indications

Quality of life improvement

Pre-operative

Post-operative

DBS works by disrupting signals

Grill WM, Snyder AN, Miocinovic S. Neuroreport. 2004;15:1137-1140.

A B

DBS Center of Excellence

• Patient Selection

• Electrode placement precision

• Post-operative care

Four additional hours/day

EarlyStim Trial

Quality of Life Improvement

DBS FOR ESSENTIAL TREMOR

Tremor reduction

DBS Off DBS On

EPILEPSY: CLOSING THE LOOP

Closed Loop System

Condition Biomarker

Implanted Computer

Target Response

Self-Programming

Chronic Monitoring

Closed-loop Neuromodulation

Benefits of RNS for Epilepsy

• Median reduction overall: 1 year 44 %; 2 years 53%

• Responder rate: 1 year 44 %; 2 years 55%

Heck CN et al. Epilepsia 2014; 55(3): 432-441.

DBS FOR OCD

Activated PET in OCD patients

Rauch SL, Jenike MA, Alpert NM, Baer L, Breiter HC, Savage CR, Fischman AJ. Arch Gen Psychiatry. 1994 Jan;51(1):62-70.

Benefits: 35% Reduction in Severity

Greenberg B, Malon D, Friehs G, Rezai A, Kubu C, Malloy P, Salloway S, Okun M, Goodman W, Rasmussen S et al. Neuropsychopharmacology 2006; 31:2384-2393.

ADVANCE IN SURGICAL TECHNIQUE

Frameless DBS

Frame-based vs Frameless

3D Printed Custom Mini-Frame

Computerized Targeting

Accuracy and Complications

• Dislodged fiducial (s): 0.1 % (3)• Infection: 0004% (1)• Starfix not fitting: 0.004% (1)• Accuracy: 1.24-1.99 mm

Konrad P, Neimat JS, Yu H, Kao CC, Remple MS, D’Haese, DawantBM. Stereotact Funct Neurosurg 2011;89:34-41.

D’Haese PF, Pallavaram S, Konrad PE, Neimat J, Fitzpatrick JM, Dawant B. Stereotact Funct Neurosurg 2010;88:81-87.

Conclusion