Julia K. Steffen

Deep brain stimulation (DBS) for Parkinson’s disease (PD) often necessitates frequent clinic visits for stimulation program optimization, with limited experience in remote patient management. Due to the resource-intensive nature of these procedures, we investigated a way to simplify stimulation optimization for these patients that allows for the continuous monitoring of symptoms while also reducing patient burden and travel distances. To this end, we prospectively recruited ten patients treated with DBS for PD to evaluate the feasibility of telemedicinal optimization in a home-based setting. Patients recorded daily videos of a modified Unified Parkinson’s Disease Rating Scale (UPDRS) III, which experienced DBS physicians located at the clinic assessed to provide instructions on adjusting stimulation settings using a handheld programmer with previously set programs as well as patient amplitude control. This study concluded with significant improvements in participants’ motor status as measured by the UPDRS-III (p = 0.0313) compared to baseline values. These findings suggest that remote video-guided optimization of DBS settings is feasible and may enhance motor outcomes for patients.

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Background Subthalamic nucleus deep brain stimulation is a well-established treatment for patients with Parkinson’s disease. Previous acute challenge studies suggested that short pulse widths might increase the therapeutic window while maintaining motor symptom control. Objectives To investigate in patients with Parkinson’s disease and nucleus subthalamicus deep brain stimulation (STN-DBS) whether short pulse width stimulation with 30µs maintains equal motor control as conventional 60µs stimulation over a period of 4 weeks. Methods In this monocentric, double-blinded, randomized crossover trial, 30 patients with Parkinson’s disease and STN-DBS were enrolled and assigned to 4 weeks of stimulation with 30µs and 4 weeks of stimulation with 60µs in randomized order (German Clinical Trials Register No. DRKS00017528). The primary outcome was the difference in motor symptom control as assessed by a motor diary. Secondary outcomes included energy consumption measures, non-motor effects, side-effects, and quality of life. Results A total of 24 patients were included in the final analysis. There was no difference in motor symptom control between the two treatment conditions. Concerning secondary outcomes there was no difference in energy consumption, non-motor symptoms, side-effects, or quality of life. On the individual level, patients preferring 30µs tended to be more dyskinetic in the 60µs setting, whereas patients preferring 60µs experienced more off-time in the 30µs setting. Conclusions Short pulse width settings (30µs) provide equal motor symptom control as conventional (60µs) stimulation without significant differences in energy consumption. Future studies are warranted to evaluate a potential benefit of short pulse width settings in patients with pronounced dyskinesia.

Postoperative choice of the most effective deep brain stimulation (DBS) contact in patients with essential tremor (ET) so far relies on lengthy clinical testing. Previous studies showed that the postoperative effectiveness of DBS contacts depends on the distance to the dentatorubrothalamic tract (DRTT). Here, we investigated whether the most effective DBS contact could be determined from calculating stimulation overlap with the individual DRTT. Seven ET patients with bilateral thalamic deep brain stimulation were included retrospectively. Tremor control was assessed for each contact during test stimulation with 2mA. Individual DRTTs were identified from diffusion tensor imaging and contacts were ranked by their stimulation overlap with the respective DRTT in relation to their clinical effectiveness. A linear mixed-effects model was calculated to determine the influence of the DRTT overlap on tremor control. In all investigated DBS leads, the contact with the best clinical effect was the contact with the highest or second-highest DRTT overlap. At the group level, the DRTT-overlap explained 26.7% of the variance in the clinical outcomes (p < 0.001). Our data suggest that the overlap with the DRTT based on individual tractography may serve as a marker to determine the most effective DBS contact in ET patients and reduce burdensome clinical testing in the future.

The new essential tremor (ET) classification defined ET-plus (ET-p) as an ET subgroup with additional neurological signs besides action tremor. While deep brain stimulation (DBS) is effective in ET, there are no studies specifically addressing DBS effects in ET-p. 44 patients with medication-refractory ET and thalamic/subthalamic DBS implanted at our center were postoperatively classified into ET and ET-p according to preoperative documentation. Tremor suppression with DBS (stimulation ON vs. preoperative baseline and vs. stimulation OFF), measured via the Fahn–Tolosa–Marin tremor rating scale (TRS), stimulation parameters, and the location of active contacts were compared between patients classified as ET and ET-p. TRS scores at baseline were higher in ET-p. ET-p patients showed comparable tremor reduction as patients with ET, albeit higher stimulation parameters were needed in ET-p. Active electrode contacts were located more dorsally in ET-p of uncertain reason. Our data show that DBS is similarly effective in ET-p compared to ET. TRS scores were higher in ET-p preoperatively, and higher stimulation parameters were needed for tremor reduction compared to ET. The latter may be related to a more dorsal location of active electrode contacts in the ET-p group of this cohort. Prospective studies are warranted to investigate DBS in ET-p further.

Neuronal network dysfunction is a hallmark of Alzheimer’s disease (AD). However, the underlying pathomechanisms remain unknown. We analyzed the hippocampal micronetwork in a rat model of AD at an early disease stage at the beginning of extracellular amyloid beta (Aβ) deposition. We established two-photon Ca ²⁺ -imaging in vivo in the hippocampus of rats and found hyperactivity of CA1 neurons. Patch-clamp recordings in brain slices in vitro revealed changes in the passive properties and intrinsic excitability of CA1 pyramidal neurons. Furthermore, we observed increased neuronal input resistance and prolonged action potential width in CA1 pyramidal neurons. Surprisingly, all parameters measured to quantify synaptic inhibition and excitation onto CA1 pyramidal neurons were intact suggesting a cell immanent deficit. Our data support the view that altered intrinsic excitability of CA1 neurons may precede inhibitory dysfunction at an early stage of disease progression.

Objective: To gain insights into structural networks associated with stimulation-induced dysarthria (SID) and to predict stimulation-induced worsening of intelligibility in essential tremor patients with bilateral thalamic deep brain stimulation (DBS). Methods: Monopolar reviews were conducted in 14 essential tremor patients. Testing included determination of SID thresholds, intelligibility ratings and a fast syllable repetition task. Volumes of tissue activated (VTAs) were calculated to identify discriminative fibers for stimulation-induced worsening of intelligibility in a structural connectome. The resulting fiber-based atlas structure was than validated in a leave-one-out design. Results: Fibers determined as discriminative for stimulation-induced worsening of intelligibility were mainly connected to the ipsilateral precentral gyrus as well as to both cerebellar hemispheres and the ipsilateral brainstem. In the thalamic area, they ran laterally to the thalamus and postero-medially to the subthalamic nucleus, in close proximity, mainly antero-laterally, to fibers beneficial for tremor control as published by Al-Fatly et al. (2019). The overlap of the respective clinical stimulation setting’s VTAs with these fibers explained 62.4% (p<0.001) of the variance of stimulation-induced change in intelligibility in a leave-one out analysis. Interpretation: This study demonstrates that SID in essential tremor patients is associated with both, motor cortex and cerebellar connectivity. Furthermore, the identified fiber-based atlas structure might contribute to future postoperative programming strategies to achieve optimal tremor control without speech impairment in ET patients with thalamic DBS.