Deep Brain Stimulation - DBS

Size: px

Start display at page:

Download "Deep Brain Stimulation - DBS"

Henry McDonald
5 years ago
Views:

1 Deep Brain Stimulation - DBS Technological innovations Alberto Priori Experimental Brain Therapeutics

2 INNOVATIVE FIELDS (Priori 2015)

3 STEERING STIMULATION Current steering à based on new electrodes allowing directing the EF radially and longitudinally with multiple contacts Stimulating device allwing independent control different contacts VERCISE (Boston Scientific) Steigerwald et al, Mov Disord 2016

4 STEERING STIMULATION La steering stimulation consente di avere una maggiore finestra terapeutica Verde = effetto terapeutico Rosso= effetto collaterale Experimental Alberto Brain Priori Therapeutics Steigerwald et al, Mov Disord 2016

INTERLEAVING STIMULATION Interleaving stimulation à a pair of electrodes each dekivering a different amount of charge e pulses but at the same frequency For patients not

5 INTERLEAVING STIMULATION Interleaving stimulation à a pair of electrodes each dekivering a different amount of charge e pulses but at the same frequency For patients not responding to conventional DBS Tested in PD, ET and dystonia Limitationà Time consuming programming Relatively short battery duration Miocinovic et al, Parkisonism Related Disrd 2014

6 INTERLEAVING STIMULATION Programming according to anatomical (electrode position) and clinical Zhang et al, 2016 Alberto Experimental Priori Brain Therapeutics S. Marceglia University of Milan, Italy

7 DUAL STIMULATION Delivered through a single 16- contacts electrode independently stimulating two structures Electrodes with more than 4 contacts which can be independently controlled Experimental Alberto Brain Priori Therapeutics Hollingworth et al, Brain Sci, 2017

8 ADAPTIVE DBS o CLOSED LOOP DBS NEW PARAMETERS DBS FEEDBACK ALGORITHM ANALYSIS CONTROL VARIABLE The choice of the control variable is crucial

POSSIBLE CONTROL VARIABLES Are adjunctive implants necessary? Are changes in surgical procedure required? Is the new device/implant well tolerated by the patient?

9 POSSIBLE CONTROL VARIABLES Are adjunctive implants necessary? Are changes in surgical procedure required? Is the new device/implant well tolerated by the patient? Do control variables correlate with the clinical state? Can the system be personalised to the specific cliniocal phenotype? Does the system decrease battery duration? Is there any proof-of-concept? (Arlotti 2016) Experimental Alberto Brain Priori Therapeutics

10 CONTROL VARIABLES Additional implant/equipment Changes in the surgical procedures Patient s management/acceptability Correlation with the clinical state Personalization and adaptability semg and accelerometers Cortical neurosignals Basal ganglia LFPs Neurotransmitters YES external sensors required NO the additional implant is external and does not affect the surgical procedure NO it may be difficult to manage the recording sensors and the external equipment may be uncomfortable YES/NO optimal correlation with tremor, but no correlations with rigidity and bradikinesia NO cannot be used if patients do not show tremor YES implanted cortical electrodes required YES the surgery needs to include the implant of cortical electrodes YES all the equipment is implanted YES EcoG phase amplitude coupling and M1 action potentials correlate with main PD symptoms and can be used to drive adbs YES/NO it may encode patient specific information NO LFPs are recorded from the implanted DBS electrode NO no additional implant during surgery YES the patient perceives the same system as for traditional DBS YES multiple LFP oscillations are modulated by levodopa administration, DBS, movements, and non-motor tasks even years after electrode implant YES the presence of multiple rhythms correlating with different patient s characteristics may account for inter-subject variability YES at least 4 additional CFM YES the additional CFMs need to be implanted during surgery NO - CFMs have a time life of only a few months and have to be replaced YES - the time duration of tremor-free period is comparable to the duration of increased levels of stimulation-induced dopamine release after DBS pulse trains NOT$YET$TESTED Low battery consumption YES/NO the processing can be done externally, but triggers should be sent via telemetry links YES/NO$ the$ipg$needs$to$ include$the$sensing$circuit$and$ the$feedback$algorithm YES/NO the IPG needs to include the sensing circuit and the feedback algorithm NO$ the$ipg$needs$to$include$ the$sensing$circuit$and$the$ feedback$algorithm Proof of concept YES in humans (ET) [Yamamoto et al., 2013] YES in animals [Rosin et al., 2011] YES in humans (PD) [Little et al., 2013; Rosa et al., 2015; Little et al., 2015] NO

11 ACCELEROMETRY & EMG Processing and control policy Acc semg IPG Tremor onset prediction in 4 PD patients (Basu et. al 2013): 100% sensitivity 80% accuracy (Shukla et al.2012, Shukla et al.2013, Basu et al.2013, Yamamoto et al. 2013)

12 ACCELEROMETRY (Cagnan et al.2017) PATIENTS WITH ET

13 ACCELEROMETRY semg and accelerometers Additional implant/equipment YES external sensors required Changes in the surgical procedures NO the additional implant is external and does not affect the surgical procedure Personalization and adaptability NO cannot be used if patients do not show tremor Patient s management/acceptability NO it may be difficult to NO it may be difficult to manage the recording sensors and the external equipment may be uncomfortable Low battery consumption Proof of concept YES/NO the processing can be done externally, but triggers should be sent via telemetry links YES in humans (ET) [Yamamoto et al., 2013] Correlation with the clinical state YES/NO optimal correlation with tremor, but no correlations with rigidity and bradikinesia

14 ECoG ieeg seeg CORTICAL BIOPOTENTIAL Single and Multi-unit activity based on micro-electrode arrays (MEA) Electrocorticography (ECoG) Surface electroencephalography (seeg) Processing and control policy IPG (Rosin et al.2011) (Hemptinne et al.2015) (Herron et al.2015)

15 CORTICAL BIOPOTENTIAL Cortical neurosignals Additional implant/equipment YES implanted cortical electrodes required Changes in the surgical procedures YES the surgery needs to include the implant of cortical electrodes Personalization and adaptability YES/NO it may encode patient specific information Patient s management/acceptability YES all the equipment is implanted Low battery consumption YES/NO$ the$ipg$needs$to$ include$the$sensing$circuit$and$ the$feedback$algorithm Correlation with the clinical state YES EcoG phase amplitude coupling and M1 action potentials correlate with main PD symptoms and can be used to drive adbs Proof of concept YES in animals [Rosin et al., 2011]

16 LFPs NEUROCHEMICAL SIGNALS Processing and control policy IPG DBS CHANGES NEUROTRASMITTER CONCENTRATION à CLOSED LOOP WITH DOPAMINE CONCENTRATION (Chang SY et al.2013; Graham et al, 2014)

17 NEUROCHEMICAL SIGNALS Neurotransmitters Additional implant/equipment YES at least 4 additional CFM Changes in the surgical procedures YES the additional CFMs need to be implanted during surgery Patient s management/acceptability Correlation with the clinical state NO - CFMs have a time life of only a few months and have to be replaced YES - the time duration of tremor-free period is comparable to the duration of increased levels of stimulation-induced dopamine release after DBS pulse trains Personalization and adaptability Low battery consumption Proof of concept NOT$YET$TESTED NO$ the$ipg$needs$to$include$ the$sensing$circuit$and$the$ feedback$algorithm NO

18 LOCAL FIELD POTENTIALS (LFPs) DEEP EEG ACTIVITY DBS electrode Neuronal population Local field potential

19 LFPs LOCAL FIELD POTENTIALS Processing and control policy IPG LFPs CAN BE CAPTURED BY THE SAME ELECTRODE DELIVERING DBS à 1.No additional implant 2.No changes in surgical procedure 3. acceptable by the patients as conventional DBS Experimental Brain Therapeutics Alberto Priori University of Milan, S. Marceglia Italy

20 LFPs LFPs correlate with the clinical state Processing and control policy IPG Risposta alla terapia dopaminergica (Priori et al 2004)

21 LFPs LFPs correlate with the clinical state Processing and control policy IPG Risposta al movimento volontario Correlazione a rigidità e bradicinesia (Kuhn et al 2009) (Foffani et al 2005)

22 LFPs LFPs correlate with the clinical state Processing and control policy IPG Dyskinesias (Alonso-French et al 2006) (Foffani et al, 2005) (Rodriguez-Oroz et al 2011)

23 LFPs correlate with the clinical state Response to DBS (Quinn et al, 2015)

24 adbs IN HUMANS: APPROACH 1 A B Rosa et al e 2017 Arlotti et al, 2017 Voltage modulation of stimulation in function of the STN beta power

25 adbs IN HUMANS: APPROACH 2 Little et al Off/on DBS in function of a given beta power level Little et al. 2015

26 COORDINATED-RESET DBS train of high frequency through electrodes different from those implanted Tested in primate and humans à beta reduction and clinical improvement Adamcich et al, Mov Disord, 2014

Design Considerations and Clinical Applications of Closed-Loop Neural Disorder Control SoCs

22nd Asia and South Pacific Design Automation Conference (ASP-DAC 2017) Special Session 4S: Invited Talk Design Considerations and Clinical Applications of Closed-Loop Neural Disorder Control SoCs Chung-Yu