Deep Brain Stimulation - StatPearls - NCBI

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Continuing Education Activity
Deep brain stimulation (DBS) was first approved in the 1990s for the treatment of
movement disorders. DBS has the potential to offer symptom resolution for a variety of
disease processes. DBS involves the placement of electrodes adjacent to deep
structures in the brain. These electrodes are then connected, by a wire, to a pulse
generator which is subcutaneously implanted into the chest wall. The pulse generator is
controlled by a computer, which ultimately gives instructions to the electrodes to fire.
This activity explains the application of DBS and reviews the role of the interprofessional
team in improving care for patients undergoing deep brain stimulation.
Objectives:
 Identify the indications for deep brain stimulation.
 Summarize the risks associated with deep brain stimulation.
 Outline the targeted structures for various deep brain stimulation indications.
 Review the importance of collaboration and communication among the
interprofessional team to ensure the appropriate selection of candidates for deep
brain stimulation and to enhance postoperative management.

Introduction
Since the discovery of localized activation of the motor cortex in the late 19th century,
electrical manipulation of the brain has frequently been the focus of scientific
investigations. Following the revelation of the electrical properties of the motor cortex,
subsequent mapping of cortical function was completed. This was followed in the 1950s,
by the identification of deep structures of the brain via intraoperative stimulation.
Theories of treating neurologic disorders with chronic stimulation began to emerge over
the proceeding decade. By the 1970s, documentation of the management of pain,
movement disorders, and epilepsy through the application of chronic stimulation was
made evident. Eventually, in the 1990s, by combining the technologies of the
implantable pacemaker with chronically implanted deep electrodes, the discovery of
deep brain stimulation (DBS) was made possible.[1]

Anatomy and Physiology

The deep brain stimulation (DBS) apparatus consists of electrodes implanted adjacent
to specific deep brain structures, which are then connected to a pacemaker-like
machine (pulse generator) that is implanted on the chest wall, via a subcutaneous wire.
Stimulation parameters are then relayed by a computer to the pulse generator,
appropriating proper amplitudes, frequencies, and pulse width. Common structures
targeted by DBS include the subthalamic nucleus (STN), globus pallidus interna (GPi),
and the ventral intermediate nucleus of the thalamus (VIM).[2]
The precise mechanism of the resultant therapeutic effects of deep brain stimulation
remains unclear; however, theories are plenty. As implied by the recounting of the
surplus of possible applications, stimulation of the deep brain structures influences a
variety of circuits involved in neuronal functioning. Therapeutic effects are incumbent
upon physiologic properties of cells, surface areas of stimulated structures, the
amplitude and temporal properties of the stimulation, and lastly, the characteristics of
the underlying pathophysiology of different disease states. Imaging and physiologic
studies corroborate the hypothesis that the ultimate effect of deep brain stimulation is
the increase of the firing of the targeted neurons.[1]

Indications
Deep brain stimulation (DBS) is approved by the United States Food and Drug
Administration (FDA) for the treatment of essential tremors, dystonia, Parkinson
disease, and treatment-refractory obsessive-compulsive disease (OCD).[2]
Since the nascent stages of its discovery, DBS technology has increasingly gained
application and use. The initial implementation of DBS was for the treatment of
essential tremor (ET) and the tremor of Parkinson disease (PD).[3][4] Studies indicate
that stimulation of the “ventral intermediate nucleus of the thalamus, via DBS, results in
the average tremor reduction of over 80%.”[5][6][7] Stimulation of the globus pallidus
internus has demonstrated a reduction of major motor manifestations of PD, including,
but not limited, to dopaminergic induced dyskinesias.[8] Stimulation of the GPi is
believed to reduce parkinsonian akinesia and rigidity by normalizing the firing frequency
of the dysfunctional GPi.[9] Improvement of gait, tremor, and bradykinesia has been
shown via stimulation of the subthalamic nucleus.[10][11] Stimulation of the
parafascicular and sensory relay nuclei of the thalamus has demonstrated analgesic
properties.[12][13]
In 1999, the first psychiatric indication for DBS was published.[2] Since that initial
publication, many studies focusing on DBS for treatment-resistant psychiatric illnesses
have been performed. More recently, DBS has been found to have beneficial effects in
Tourette Syndrome, via stimulation of the centromedian-parafascicular complex of the
thalamus, along with the GPi and the anterior limb of the internal capsule. Perhaps most
notably is the application of DBS for obsessive-compulsive disorder (OCD) and
treatment-refractory depression.[14] DBS of the subgenual cingulate white matter has
demonstrated efficacy in the improvement of mood in those afflicted with treatment-
resistant depression, whereas DBS of the bilateral anterior limbs of the internal capsules
has shown a reduction of OCD-related symptoms.[15] Evidence demonstrating the
resolution of OCD symptomatology by targeting either the ventral capsule/ventral
striatum or the STN led to the FDA approval of DBS for treatment-refractory OCD, in
2009.[2] The first documented application of DBS for treatment-resistant depression
(TRD) was in 2009. Hypothesized targets for the treatment of TRD are the subgenual
anterior cingulate cortex, ventral capsule/ventral striatum, nucleus accumbens, and the
medial forebrain bundle.[2] Future psychiatric indications that are currently being
studied include addiction, autism, anorexia nervosa, anxiety disorders, and
schizophrenia.

Contraindications
Deep brain stimulation (DBS) has fairly minimal absolute contraindications. DBS is
contraindicated in patients who cannot properly operate the neurostimulator. Once
implanted, patients with deep brain stimulators should not undergo full-body magnetic
resonance imaging scans (MRIs), transcranial magnetic stimulation, and diathermy.[16]
Equipment
Proper DBS equipment includes a lead with electrodes, a wire, a pulse generator, along
with the corresponding tools for brain surgery and chest wall implantation.[2]

Personnel
The procedure requires specific personnel. Quintessential to the surgery is an
experienced neurosurgeon, along with their associated staff. As DBS is currently
indicated for mostly neurologic disorders, it is more likely that the referring physician
will be a neurologist. However, for indications such as treatment-refractory OCD, a
psychiatrist will often fill the role of the referring physician sometimes in discussion with
a neurologist. Moreover, the referring physician, along with the neurosurgeon, will
discuss the case and identify the structures of pertinence to be stimulated by the
implanted device.[2]

Preparation
Prior to the procedure, the patient will need to be medically cleared to undergo surgery,
to ensure that DBS is a safe and appropriate option. Once cleared, the patient will
undergo brain-imaging studies to visualize locations for implantation of the electrodes.
[16]

Technique or Treatment
Once underway, the surgical team will fit the patient with a special frame to immobilize
head movement during the surgery. This frame is called a stereotactic head frame.
Surgery is commonly performed under general anesthesia, but local anesthesia is also a
viable alternative. Intriguingly, the brain itself does not require an anesthetic itself, as it
lacks pain receptors. The surgeon then implants a thin wire lead to the structures that
were identified pre-surgery. Tiny electrodes at the end of the wire will contact the
aforementioned structures. The lead is then connected to a wire which runs just
superficially to the skin, which ultimately connects to a pulse generator within the chest
wall. Both the neurosurgeon and neurologist will closely monitor brain function
throughout the procedure to ensure appropriate electrode placement.
The subsequent chest wall surgery involves the placement of the pulse generator just
under the skin near the clavicle. Unlike the preceding procedure, chest wall surgery
requires general anesthesia. The pulse generator is then connected to a special remote
control.[2]

Complications
Of equal ambiguity is the side effect profile of deep brain stimulation. Whereas
the surgical complications implicated with deep brain stimulation, such as hemorrhage,
surgical revision of hardware, and infection, are more apparent and objective, the
assessment of psychiatric and neurologic manifestations of adverse effects tend to be
more discreet and protean, from patient to patient. This vagueness is multifactorial in
origin. Firstly, patients may simply not relay these complaints to their respective
physicians. Reciprocally, the physician, in turn, may not ask the appropriate questions
in order to elucidate ongoing adverse side effects. It is plausible that even if side effects
are reported, they may not be documented if they do not meet some arbitrary threshold
level of severity. Moreover, it is sometimes hard to differentiate between pre-existing
symptoms and comorbidities from the precipitating side effects of DBS. Furthermore,
certain side effects tend to manifest over time and occur with latency. An example of
this insidious onset is axial symptoms in Parkinson disease. Lastly, as science further
evolves and behavioral derivatives of neurocircuitry are mapped out, it is possible that
what was once celebrated as therapeutic gains from DBS treatment, will now be
regarded as red flags. For example, whereas the spontaneous onset of initiative in STN-
stimulated Parkinson disease patients was once applauded as progress, it is now,
unfortunately, considered to be the pathological manifestation of disturbed impulse
control.[17] However, current scientific literature demonstrates that deep brain
stimulation is relatively safe overall and is associated with only minimal and perhaps
negligible side effect profile. Nonetheless, the following includes a list of reported side
effects: mild gait or speech disturbances, affective liability, worsened depression,
seizure, difficulty concentrating, confusion, and headache.

Clinical Significance
Deep brain stimulation has the potential for robust application, and has specifically
been heralded as offering "a new life for people with Parkinson disease."[16] DBS has
already been awarded FDA approval for essential tremor, dystonia, Parkinson disease,
and treatment-refractory obsessive-compulsive disease. Ongoing studies are
investigating the possible off-label use in addiction, autism, anorexia nervosa, anxiety
disorders, and schizophrenia.

Enhancing Healthcare Team Outcomes

The literature is abundant, with studies demonstrating the benefits of
interprofessional collaboration. Patient outcomes such as decreasing morbidity and
mortality rates, optimizing medication dosages, and reducing preventable adverse drug
events have been shown to improve via interprofessional collaboration.[18][Level 4] Not
only does this benefit the patient, but it also benefits the health care workers, by
increasing job satisfaction and reducing extra work.[18] Successful deep brain
stimulation (DBS) requires integrative, collaborative communication, and care. An
interprofessional DBS team should include an experienced surgeon (with expertise in
functional neurosurgery), a movement disorder neurologist, psychiatrist,
neuropsychologist, and neuropsychologist. The nurse plays an integral role in assisting
the patient gain maximum benefit from the surgical intervention. All healthcare workers
must be engaged and in sync for the patient to achieve optimal results.
"This research was supported (in whole or part) by HCA Healthcare and/or an HCA
Healthcare affiliated entity. The views expressed in this publication represent those of
the author(s) and do not necessarily represent the official views of HCA Healthcare or
any of its affiliated entities."