SUPPLEMENTAL DIGITAL CONTENT

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Natalie Cora Welch
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1 SUPPLEMENTAL DIGITAL CONTENT FIGURE 1. Unilateral subthalamic nucleus (STN) deep brain stimulation (DBS) electrode and internal pulse generator. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

FIGURE 2. A DBS electrode was advanced to the STN, and in a parallel track 2 mm away microelectrode recording (MER) of STN neurons was carried out (left).

2 FIGURE 2. A DBS electrode was advanced to the STN, and in a parallel track 2 mm away microelectrode recording (MER) of STN neurons was carried out (left). Spikes were sorted by amplitude and waveform using Matlab TM (upper right), and neurons were recorded with increasing stimulus intensity (lower right). Adapted from Figure 2 in Carlson JD, Cleary D, Cetas J, Heinricher M, Burchiel K. Deep Brain Stimulation (DBS) Does Not Silence Neurons in Subthalamic Nucleus in Parkinson's Patients. J Neurophysiol. 2010;103(2): As an original author, no permission is required. Copyright 2010 the American Physiological Society.

FIGURE 3. Stimulation of the subthalamic nucleus (STN) with DBS during simultaneous microelectrode recording (MER) of STN neurons 2 mm from the stimulating electrode, as shown in Figure 2.

3 FIGURE 3. Stimulation of the subthalamic nucleus (STN) with DBS during simultaneous microelectrode recording (MER) of STN neurons 2 mm from the stimulating electrode, as shown in Figure Hz stimulation in STN did not alter neuronal firing rate during stimulation (red area on the figure) compared to pre- and post-stimulation. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

FIGURE 4. Stimulation of the subthalamic nucleus (STN) with DBS during simultaneous microelectrode recording (MER) of STN neurons 2 mm from the stimulating electrode, as shown in Figure 2.

4 FIGURE 4. Stimulation of the subthalamic nucleus (STN) with DBS during simultaneous microelectrode recording (MER) of STN neurons 2 mm from the stimulating electrode, as shown in Figure Hz stimulation does not alter neuronal firing rate, but does change the pattern of discharge, from predominantly bursting and tonic to more random firing. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

In GPI, DBS at 100 Hz produces entrainment of neuronal firing after the cessation of stimulation (A, C), brief inhibition of firing followed by several milliseconds of increased firing rate

5 FIGURE 5. Stimulation of the globus pallidus internus (GPI) with DBS during simultaneous microelectrode recording (MER) of GPI neurons 2 mm from the stimulating electrode, as shown in Figure 2. In GPI, DBS at 100 Hz produces entrainment of neuronal firing after the cessation of stimulation (A, C), brief inhibition of firing followed by several milliseconds of increased firing rate ( rebound, B), or no effect (D). Adapted from Figure 5 in Cleary DR, Raslan AM, Rubin JE, Bahgat D, Viswanathan A, Heinricher MM, Burchiel KJ. Deep brain stimulation entrains local neuronal firing in human globus pallidus internus. J Neurophysiol. 2013;109(4): As an original author, no permission is required. Copyright 2010 the American Physiological Society. A B C D

6 FIGURE 6. Microelectrode recording can be used to identify target structures such as the globus pallidus internus (GPI) by their characteristic discharge patterns. In this recording, a track to the GPI passes through putamen and globus pallidus externus (GPE) to globus pallidus internus (GPI), which shows both high-frequency tonic discharging cells and neurons with phasic bursting discharges. MER is one method for localizing DBS electrodes. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

7 FIGURE 7. Image of preoperative MRI scan fused with a postoperative CT scan on the Medtronic StealthStation TM using Framelink TM software. The green and yellow colored lines represent the planned trajectory of the right and left GPI electrodes, respectively. The overlapping image of the distal electrode contact can be seen at the end of each trajectory, showing accurate location of each electrode. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

8 FIGURE 8. The offset of the actual position of the centrum of the target DBS electrode from the planned target is defined as accuracy. The calculation of accuracy is defined by 2 measures: offplan (T) and past target (V). These 2 parameters define a cylinder with a radius of (T). Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

9 FIGURE 9. Off-target DBS electrode positional errors appear to be related to the target itself. GPI targets have the lowest error, and VIM has the highest. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

10 FIGURE 10. Deviation of DBS target electrode from the planned target. Medial deviation appears to be the most common error. Error is expressed in percent of patients exhibiting a particular direction of off-target placement. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

FIGURE 11. Correlation of the deviation from the planned electrode trajectory with the distance of the trajectory from the lateral margin of the frontal horn (r 2 = 0.419, P <.05, n = 19).

11 FIGURE 11. Correlation of the deviation from the planned electrode trajectory with the distance of the trajectory from the lateral margin of the frontal horn (r 2 = 0.419, P <.05, n = 19). Adapted from Figure 2 in Burchiel KJ, McCartney S, Lee A, Raslan AM. Accuracy of deep brain stimulation electrode placement using intraoperative computed tomography without microelectrode recording. J Neurosurg. 2013;119(2): With permission from Journal of Neurosurgery.

12 FIGURE 12. Comparison of the detection of intracranial air by CT immediately postoperatively after traditional DBS performed in an awake patient, and DBS implantation performed under general anesthesia ( asleep ). The initial asleep DBS experience (#1-54) is also compared to subsequent cases (#55-109). Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

FIGURE 13. Cost from 30 days prior to, to 30 days following implantation of bilateral DBS leads and internal pulse generator (IPG). OHSU s costs are shown in the red dashed line.

13 FIGURE 13. Cost from 30 days prior to, to 30 days following implantation of bilateral DBS leads and internal pulse generator (IPG). OHSU s costs are shown in the red dashed line. Adapted from Figure 1 in Jacob RL, Geddes J, McCartney S, Burchiel KJ. Cost analysis of awake versus asleep deep brain stimulation: a single academic health center experience. J Neurosurg. 2016;124(5) With permission from Journal of Neurosurgery.

FIGURE 14. Average total cost per discharge, procedure 02.93; adult inpatient cost data from 27 UHC hospitals, 2010-2013. The arrow points to the OHSU cost.

14 FIGURE 14. Average total cost per discharge, procedure 02.93; adult inpatient cost data from 27 UHC hospitals, The arrow points to the OHSU cost. Adapted from Figure 2 in Jacob RL, Geddes J, McCartney S, Burchiel KJ. Cost analysis of awake versus asleep deep brain stimulation: a single academic health center experience. J Neurosurg. 2016;124(5) With permission from Journal of Neurosurgery.

15 FIGURE 15. Postoperative outcome of 30 patients who underwent asleep DBS at OHSU using intraoperative CT (ict), compared to the same parameters measured in the VA/NIH Cooperative Trial on DBS, in which microelectrode recording (MER) was used for target localization. There were no statistically significant differences between ict and MER clinical outcomes. Copyright 2010 Oregon Health & Science University. Used with permission from Oregon Health & Science University.

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