Deep brain stimulation

DEEP BRAIN STIMULATION(DBS)A BRAIN PACEMAKER FOR

NEUROLOGICAL DISORDERS

PRESENTED BY: SHIBANI PRASAD

4/6/2013 1Dept. of IT,BMSPI-(2012 -13) ,DEEP BRAIN STIMULATION- A BRAIN PACEMAKER FOR


CONTENTS• INTRODUCTION• COMPONENTS AND ITS SPECIFICATIONS• PLACEMENT OF THE COMPONENTS• METHODOLOGY OF SURGERY• DISEASES TREATED USING DBS• LIMITATIONS OF DBS SURGERY• FUTURE SCOPE AND ENHANCEMENT• DISCUSSIONS ON CURRENT RESEARCH• CONCLUSIONS• MANUFACTURING COMPANIES• HEALTH CENTRES IN INDIA• REFERENCES

4/6/2013 2Dept. of IT,BMSPI-(2012 -13) ,DEEP BRAIN STIMULATION- A BRAIN PACEMAKER FOR


Dept. of IT,BMSPI-(2012 -13) ,DEEP BRAIN STIMULATION- A BRAIN PACEMAKER FOR NEUROLOGICAL DISORDERS

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IntroductionWhat is Deep Brain Stimulation ?

• Deep Brain Stimulation(DBS) is a surgical treatment which implants a medical device called a Brain Pacemaker.

• DBS sends electrical impulse to specific parts of the brain which need to be stimulated .

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Fig:1 IPG sending impulses to the nerve cells


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Deep Brain Stimulation

• DBS in selected brain regions has provided effective benefits for the diseases such as,

(i) Parkinson’s Disease (ii) Chronic pain (iii) Tremor (iv) Dystonia• It is now considered the neurosurgical therapy of

choice for the movement disorders.

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Fig : 2 (i) Parkinson’s Disease

Fig : 2 (iii) Tremor

Fig : 2 (iv) Dystonia

Fig : 2 (ii) Chronic Pain


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• DBS system consists of 3 parts, (i)The IPG : is a battery-powered neurostimulator

encased in a titanium housing, which sends electrical pulses to the brain to interfere with neural activity at the target site.

(ii)The lead: is a coiled wire insulated in polyurethane with four platinum iridium electrodes .

(iii)The Extension: it is an insulated wire. The lead is connected to the IPG by the extension.

Components of DBS

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Fig : 3 (i) IPG[9]

Fig : 3 (ii) LEAD[9]

Fig : 3 (iii) EXTENSION[9]


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Block Diagram of an IPG

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Fig:4 Block Diagram of an IPG [9]


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Specifications(i) Implant pulse generator[9]:• Model 37601(for PD )• Size: 65 x 49 x 15 mm (2.6 x 1.9 x 0.6 in)• Weight: 67 g (2.4 oz)• Battery Type: Primary cell• Channels: 2(ii) Lead[9]:• Model 3387 ( for PD)• Model 3391 ( for OCD )• Firm tungsten stylet for accurate targeting and placement• Soft, blunt tip for passage through tissue• Burr hole ring and cap for secure anchoring

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Fig :5 (ii) Lead 3387

Fig :5 (i) IPG


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Specifications (contd..)

(iii) Extension[9]:• Model 7483 ( PD) >Lengths : 40, 60, 95 cm• Model 37086 (OCD) >Lengths : 10 to 110 cm

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Fig :5(iii) Extension 7483


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Physical Specifications Of IPGPhysical specifications[9]

Height 55 mm ( 2.2 inch )

length 60 mm ( 2.4 inch )

Case Thickness 11 mm ( 0.4 inch )

Weight Model 37602: 45 g (1.6 oz)Model 37603: 44 g (1.6 oz)

Volume Model 37602: 28 ccModel 37603: 27 cc

Battery type Primary cell

Connector type Model 37202: Quadripolar, compatible with 2-pronged extensionModel 37603: Octapolar, compatible with Stretch-Coil extension

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Therapy Specifications of IPGTherapy specifications[9]

Longevity 4–6 years*

Amplitude 0 - 10.5 V (voltage mode)0 - 25.5 mA (current mode)

Rate 2 - 250 Hz (voltage mode)30 - 250 Hz (current mode)

Pulse Width 60 to 450 µs

Number of Defined Groups 1 to 4

Number of Programs per Group 1 to 2

Electrode Configuration Up to 4 electrodes per lead defined as anode, cathode or Off

* For typical PD patients , the device longevity depends on the programmed settings.

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Placement of the Components• The IPG is placed subcutaneously below the clavicle

or in some cases, the abdomen. • The Lead is placed in one of three areas of the brain

and it is connected to the IPG by the extension .• The Extension runs from the head, down the side of

the neck, behind the ear to the IPG.

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Fig :6 Placement of the components


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Methodology of Surgery It involves :• The selection of patients. DBS is not used in the

following patients,Patients with a previous Surgical Ablation procedurePatients who are pregnantPatients under the age of 18 and above 75.• The implantation of DBS device, > DBS electrode placement > DBS battery placement.

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Fig : 7 A patient undergoing DBS surgery


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Methodology of Surgery( contd..)• DBS electrode placement has 2 steps: (i) Planning step: In this step an anatomical point is

defined using high definition MRI. (ii) Intraoperative stage :

The placement of DBS leads are accomplished by stereotactic apparatus.

• DBS battery placement: > Battery is placed below the clavicle

or in some cases the abdomen.

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Fig : 8 A Stereotactic apparatus[13]


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Surgery Procedure

• Step 1:Attachment of stereotactic frame.• Step 2: Take MRI or CT scan• Step 3: Skin and Skull incision• Step 4: Insert electrode in the brain• Step 5. Stimulate the brain cells• Step 6: Closure

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Fig : 9(ii) Step 3Fig : 9(iii) Step 4

Fig : 9(iv) Step 5

Fig : 9(i) Step 1


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Diseases treated using DBS -Parkinson’s Disease

• Symptoms : Tremor, rigidity, and postural instability.• Sites of treatment : The Subthalamic Nucleus (STN)

and the Globus Pallidus Interna (GPI).• Approval : It is approved by FDA.

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Fig : 10(ii) Parkinson’s disease affected brain[13]

Fig : 10(i) A patient with IPG


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Chronic Pain• Causes : Neuropathic pain, Nociceptive pain.• Sites of treatment : The Peria Queductal Gray and

Periventricular gray for nociceptive pain, Ventral Posterolateral nucleus and Ventral Posteromedial Nucleus for neuropathic pain .

• Approval : It is approved and recommended.

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Fig : 11 Chronic pain existing parts of brain[13]

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Major Depression• Causes : Treatment resistant depression (TRD),

Obsessive compulsive disoirder (OCD)• Sites of treatment : Ventral Capsule/Ventral

Striatum, Inferior Thalamic Peduncle and the Lateral Habenula.

• Approval : DBS for TRD and OCD are not approved in North America.

4/6/2013Dept. of IT,BMSPI-(2012 -13) ,DEEP BRAIN STIMULATION- A BRAIN PACEMAKER FOR


Fig : 12 Brain parts reason for depression.


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Tourette Syndrome• Causes : Inherited disorder.• Sites of treatment : Cortical and Subcortical regions,

the Thalamus, Basal Ganglia and Frontal Cortex.• Approval : Approved but not recommended on

children except those in severe cases.

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Fig : 13(i) Tourette syndrome affected parts of the brain.

Fig : 13(ii) Tourette syndrome affected child treated with DBS


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Limitations of DBS surgery• Wound infection, postoperative headache(Fig 14(ii) )

and worsening/irritable mood and increased suicidality.

• One of the major risks is haemorrhaging(Fig:14(i) ), or excessive bleeding caused by damage to blood vessels.

• It is expensive.

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Fig : 14(i) Hemorrhage of the brain.

Fig :14(ii) Headache after surgery


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Future scope and Enhancement• Focuses on, An adaptive closed loop controlled DBS(Fig:15) helps in

automatic adaptation of IPG according to the feedback it receives[2].

The device which automatically senses the need for increased voltage.

Improving longevity. Reduction in size. Reduction in cost. Low risk.

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Fig :15 An adaptive closed loop controlled DBS[2]


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Discussions on Current Research

• DBS can be eventually implemented for the side-effects caused by PD i.e., Word fluency worsening and also can be witnessed to help the visually impaired[3].

• Wireless wrist-wearable (Fig :16) wake/sleep identification device for closed-loop deep brain stimulation[4].

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Fig :16 Wireless wrist wearable.[4]


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Existing DBS- Restoring Sight to the blind.• Direct brain implants have been used to treat non-

congenital blindness and “ locked-in syndrome”. • One of the first scientists to come up with a working

brain interface to restore sight was private researcher William Dobell[11].

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Fig : 17 Jens Naumann - DBS implemented patient[11]


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• Initially BCI contained 68 electrodes which were implanted onto visual cortex.

• It produced phosphenes, which succeeded in sensing lights.

• He was made to hooked up to a large mainframe. * BCI- Brain Computer Interface.

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DBS- Restoring Sight to the blind. (contd..)

Fig :18 DBS for visually impaired


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Future enhancement in BCI

• In theory , Non-invasive BCI is under research which can be implanted under skull rather than into the gray matter.

• They are found to produce better resolution, less risk of forming scar tissue.

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Eye Microchip with implanted DBS• Scientists are developing an electronic eye implant

which they believe could help millions of people to see again.

• The microchip works by stimulating cells around the retina. This in turn stimulates cells in the brain, helping people to see [7].

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Fig :19 Eye Microchip with implanted DBS.[7]


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Conclusions

• Advances in the neurosciences will continue to drive the applications of DBS.

• Finally, innovations in biomedical engineering and technology will continue to be applied to DBS.

• The ideal platform for the development of these innovations is the active collaboration between basic scientists, engineers and clinicians.

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Manufacturing companies

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Health centres in India • Kokilaben Dhirubhai Ambani Hospital, Mumbai • Apollo Hospitals, Chennai• Sterling Hospital, Ahmedabad (Fig:19) • Columbia Asia Referral Hospital, Bangalore.

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Fig :20 A patient treated with DBS at Ahmedabad hospital.[8]


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References[1] Chima O. Oluigbo, Asem Salma, and Ali R. Rezai,” Clinial Application Review”, ieee reviews

in biomedical engineering, vol. 5, 2012.

[2] Sabato Santaniello, Member, IEEE, Giovanni Fiengo, Member, IEEE, Luigi Glielmo, Senior Member, IEEE, and Warren M. Grill, Senior Member, IEEE,“Closed-Loop Control of Deep Brain Stimulation:A Simulation Study”, ieee transactions on neural systems and rehabilitation engineering, vol. 19, no. 1, february 2011 15.

[3] yuka watanabe, tubasa sada, ryotaro takashima, masatsugu takano, hiromi tateno and koichi hirata department o/neurology dokkyo medical university 880 kitakobayashi, mibu, shimotuga, tochigi, japan [email protected],” Evaluation of the word fluency in parkinson's disease patients treated with deep brain stimulation -a pilot study”, proceedings of 20121cme international conference on complex medical engineering july i - 4, kobe, japan.

[4] Y. Chen, H.W. Hao, Y.X. Hu and L.M. Li,” Wireless wrist-wearable wake/sleep identification device for closed-loop deep brain stimulation”, Electronics letters 28th march 2013 vol. 49 no. 7.

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References (contd..)

[5] Zitella LM, Mohsenian K, Pahwa M, Gloeckner C, Johnson MD.,“Computational modeling of pedunculopontine nucleus deep brain stimulation.”,Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA.

[6] Jan Gimsaa, Beate Habela, Ute Schreiberb, Ursula van Rienenb,,”Choosing electrodes for deep brain stimulation experiments–electrochemical considerations”, Department of Biology, University of Rostock,Germanyb University of Rostock, Faculty of Computer Science and Electrical Engineering, Chair of Theoretical Electrotechnics,Albert-Einstein-Str. 2, D-18059 Rostock, Germany. Journal of Neuroscience Methods 142 (2005) 251–265.

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Online References[7]http://news.bbc.co.uk/2/hi/health/2547491.stm

[8]http://articles.timesofindia.indiatimes.com/keyword/deep-brain-stimulation

[9]http://professional.medtronic.com/pt/neuro/dbsmd/prod/dbs-extension-model-37086/index.htm#.UasK_tJyBZ8

[10]http://science.howstuffworks.com/life/inside-the-mind/human-brain/deep-brain-stimulation6.html

[11]http://jacobbollinger.com/?page_id=13

[12]http://www.fda.gov/Safety/Recalls/ucm350691.html

[13]http://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/deep_brain_stimulation_135,38/

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Deep brain stimulation

Technology

brain pacemaker

deep brain stimulationdbs

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selected brain regions

neurological disorders1

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neurological disorders3

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