Posts tagged DBS

Available research evidence supports the use of deep brain stimulation (DBS) for patients with obsessive-compulsive disorder (OCD) who don’t respond to other treatments, concludes a review in the October issue of Neurosurgery, official journal of the Congress of Neurological Surgeons (CNS). The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Based on evidence, two specific bilateral DBS techniques are recommended for treatment of carefully selected patients with OCD, according to a new clinical practice guideline endorsed by the CNS and the American Association of Neurological Surgeons. While calling for further research in key areas, Dr. Clement Hamani of Toronto Western Hospital and coauthors emphasize that patients with OCD symptoms that don’t respond to other treatments should continue to have access to DBS.

Deep Brain Stimulation for OCD—What’s the Evidence?

Dr. Hamani led a multispecialty expert group in performing a systematic review of research on the effectiveness of DBS for OCD. Deep brain stimulation—placement of electrodes in specific areas of the brain, followed by electrical stimulation of those areas—has become an important treatment for patients with Parkinson’s disease and other movement disorders.

Although many patients with OCD respond well to medications and/or psychotherapy, 40 to 60 percent continue to experience symptoms despite treatment. Over the past decade, a growing number of reports have suggested that DBS may be an effective alternative in these “medically refractory” cases.

Dr. Hamani and colleagues were tasked with analyzing the supporting evidence and developing an initial clinical practice guideline for the use of DBS for patients with OCD. The review and guideline development process was sponsored by the American Society of Stereotactic and Functional Neurosurgery and the CNS. Out of more than 350 papers, the reviewers identified seven high-quality studies evaluating DBS for OCD.

Based on that evidence, they conclude that bilateral stimulation (on both sides of the brain) of two brain “targets”—areas called the subthalamic nucleus and the nucleus accumbens—can be regarded as effective treatments for OCD. In controlled clinical trials, both techniques improved OCD symptoms by around 30 percent on a standard rating scale.

While Research Proceeds, well-selected treatment-resistant severe OCD Patients Should Have Access to DBS

That evidence forms the basis for a clinical guideline stating that bilateral DBS is a “reasonable therapeutic option” for patients with severe OCD that does not respond to other treatments. The guideline also notes that there is “insufficient evidence” supporting the use of any type of unilateral DBS target (one side of the brain) for OCD.

The review highlights the difficulties of studying the effectiveness of DBS for OCD—because most patients respond to medical treatment, studies of this highly specialized treatment typically include only small numbers of patients. Dr. Hamani and coauthors identify some priorities for future research: particularly to identify the most effective brain targets and the subgroups of patients most likely to benefit.

Despite the limited evidence base, DBS therapy for OCD has been approved by the Food and Drug Administration under a humanitarian device exemption. Dr. Hamani and coauthors note that various safeguards are in place to ensure appropriate use, and prevent overuse, of DBS for OCD.

While research continues, they believe that functional neurosurgeons should continue to work with other specialists to ensure that patients with severe, medically refractory OCD continue to have access to potentially beneficial DBS therapy.

(Source: wolterskluwerhealth.com)

If you have ever said or done the wrong thing at the wrong time, you should read this. Neuroscientists at The University of Texas Health Science Center at Houston (UTHealth) and the University of California, San Diego, have successfully demonstrated a technique to enhance a form of self-control through a novel form of brain stimulation.

Study participants were asked to perform a simple behavioral task that required the braking/slowing of action – inhibition – in the brain. In each participant, the researchers first identified the specific location for this brake in the prefrontal region of the brain. Next, they increased activity in this brain region using stimulation with brief and imperceptible electrical charges. This led to increased braking – a form of enhanced self-control.

This proof-of-principle study appears in the Dec. 11 issue of The Journal of Neuroscience and its methods may one day be useful for treating attention deficit hyperactivity disorder (ADHD), Tourette’s syndrome and other severe disorders of self-control.

“There is a circuit in the brain for inhibiting or braking responses,” said Nitin Tandon, M.D., the study’s senior author and associate professor in The Vivian L. Smith Department of Neurosurgery at the UTHealth Medical School. “We believe we are the first to show that we can enhance this braking system with brain stimulation.”

A computer stimulated the prefrontal cortex exactly when braking was needed. This was done using electrodes implanted directly on the brain surface.

When the test was repeated with stimulation of a brain region outside the prefrontal cortex, there was no effect on behavior, showing the effect to be specific to the prefrontal braking system.

This was a double-blind study, meaning that participants and scientists did not know when or where the charges were being administered.

The method of electrical stimulation was novel in that it apparently enhanced prefrontal function, whereas other human brain stimulation studies mostly disrupt normal brain activity. This is the first published human study to enhance prefrontal lobe function using direct electrical stimulation, the researchers report.

The study involved four volunteers with epilepsy who agreed to participate while being monitored for seizures at the Mischer Neuroscience Institute at Memorial Hermann-Texas Medical Center (TMC). Stimulation enhanced braking in all four participants.

Tandon has been working on self-control research with researchers at the University of California, San Diego, for five years. “Our daily life is full of occasions when one must inhibit responses. For example, one must stop speaking when it’s inappropriate to the social context and stop oneself from reaching for extra candy,” said Tandon, who is a neurosurgeon with the Mischer Neuroscience Institute at Memorial Hermann-TMC. 

The researchers are quick to point out that while their results are promising, they do not yet point to the ability to improve self-control in general. In particular, this study does not show that direct electrical stimulation is a realistic option for treating human self-control disorders such as obsessive-compulsive disorder, Tourette’s syndrome and borderline personality disorder. Notably, direct electrical stimulation requires an invasive surgical procedure, which is now used only for the localization and treatment of severe epilepsy.

(Source: uth.edu)

ScienceDaily (Aug. 28, 2012) — Deep-brain stimulation (DBS) may stop uncontrollable shaking in patients with Parkinson’s disease and essential tremor by imposing its own rhythm on the brain, according to two studies published recently by University of Alabama at Birmingham researchers in the journal Movement Disorders. An article addressing brain stimulation for essential tremor was published online August 28; a related article on Parkinson’s disease was released May 30.

DBS uses an electrode implanted beneath the skin to deliver electrical pulses into the brain more than 100 times per second. Although this technology was approved by the Food and Drug Administration more than 15 years ago, it remains unclear how it reduces tremor and other symptoms of movement disorders.

With the help of electroencephalography or EEG — electrodes placed on the scalp — study authors used new techniques to suppress the electrical signal associated with the DBS electrode. That enabled the first clear, non-invasive EEG measurements of the underlying brain response during clinically effective, high-frequency brain stimulation in humans.

The results show that nerves in the cerebral cortex, the outer layer of the brain, fire with rapid and precise timing in response to individual stimulus pulses. This suggests that DBS may synchronize the firing of nerve cells and break the abnormal rhythms associated with involuntary movements in Parkinson’s disease and essential tremor.

The newly identified rhythm was captured during effective DBS treatment, so it could represent a new physiological measure of the stimulation dose, say the authors. If validated, such a yardstick could help to guide the fine-tuning of DBS stimulator settings in patients for more lasting relief, fewer side effects and less-frequent battery-replacement surgeries.

"Though it’s clear that more work is needed to better understand these initial observations, we’re very excited by our findings because they may provide a biological marker for improvement in the symptoms of these patients," says Harrison Walker, M.D., assistant professor in the UAB Department of Neurology’s Division of Movement Disorders and lead author of the study.

In current clinical practice, stimulator settings are adjusted by trial and error, requiring careful observation of changes in symptoms over multiple clinic visits. But such immediate, visual feedback may not be available as DBS is applied to neurological or psychiatric conditions such as epilepsy, severe depression or obsessive compulsive disorder. In these diseases, an effective dose measurement could be especially useful in optimizing DBS therapy.

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ScienceDaily (Aug. 20, 2012) — Scientific advances in understanding the “addiction circuitry” of the brain may lead to effective treatment for obesity using deep brain stimulation (DBS), according to a review article in the August issue of Neurosurgery, official journal of the Congress of Neurological Surgeons.

Electrical brain stimulation targeting the “dysregulated reward circuitry” could make DBS — already an accepted treatment for Parkinson’s disease — a new option for the difficult-to-treat problem of obesity. Dr. Alexander Taghva of Ohio State University and University of Southern California was lead author of the new review.

New Insights into ‘Reward Circuitry’

Obesity is a major public health problem that is notoriously difficult to treat. Although various approaches can promote weight loss, patients typically gain weight soon after the end of treatment. Drug options have shown limited success, with several products removed from the market because of serious adverse effects. Bariatric surgery is effective in many cases of obesity but has a significant failure rate and is associated with side effects.

Drug treatments for obesity have targeted the homeostatic (self-regulating) mechanism regulating appetite and body weight. The homeostatic mechanism is thought to involve the “feeding center” in the hypothalamus, which produces hormones (such as leptin and insulin) that affect feeding behavior.

Initial experiments exploring DBS as a treatment for obesity have targeted the hypothalamus. However — as with drug options focusing on the homeostatic mechanisms — success has been limited.

Possible Role of DBS for Obesity

More recent studies have explored a different mechanism: specifically, the “reward circuitry,” of the brain. Research has suggested that obesity is associated with a “relative imbalance” of the reward circuitry. Studies show that obese subjects — like those with addictive behaviors — are more impulsive and less able to delay gratification. The reward circuitry is intimately interconnected with the homeostatic mechanisms.

Together, these studies raise the possibility of new DBS approaches to the treatment of obesity. In DBS, a small electrode is surgically placed in a precise location in the brain. A mild electrical current is delivered to stimulate that area of the brain, with the goal of interrupting abnormal activity. Deep brain stimulation has become a standard and effective treatment for movement disorders such as Parkinson’s disease.

Just as stimulation of the brain areas responsible for abnormal movement helps “turn off” tremors in patients with Parkinson’s disease, stimulation of the areas involved in dysregulated reward circuitry might be able to “turn off” abnormal feeding behaviors in obese patients. The authors outline evidence implicating several different brain areas involved in the brain’s reward circuitry — particularly the “frontostriatal circuitry” — which could be useful targets for DBS.

Previous reports in individual patients have suggested that DBS performed for other reasons — particularly severe obsessive-compulsive disorder — have unexpectedly had unpredicted beneficial effects on addictive behaviors like smoking and overeating. Dr. Taghva and colleagues hope their review will open the way to further exploration of DBS as part of new and effective strategies for the treatment of obesity, perhaps in combination with therapies targeting the homeostatic mechanism.

Source: Science Daily