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Robert cartman

Incorrect location of an electrode

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My wife who is now 62 years of age intiially had Bilateral Deep Brain Stimulation of the Sub-thalmic nucleus in October 2009 for tremor predominant parkinsons. (without stimulation her tremor is extreme in all limbs, although currently she experiences few other parkinsonian symptoms).

in October 2012, due to 'complications' during a routine replacement of her IPG, her nuero-surgeon also found it necessary to relace the left electrode,

 

As a consequence of further negative issues arising from the above procedures ( 3 in total) it became necessary to seek a second opinion from the leading Professor in this field, who after examining her scans, found that the left electrode is 'high and lateral'. Despite this the left electrode has not been repositioned and with stimulation the tremor is fully contolled.

 

However since the replacement of the left electrode in 2012 and despite numerous programming sessions my wife experiences frequent bouts of nausea (at least once a week) and also (daily) the sudden onset of periods where her whole body is 'sweating' for anything between several minutes to several hours. In addition replacement of this electrode has had a negative impact upon her speech.She did not experience these symptoms prior to the incorrect replacement/repositioning of the left electrode in October 2012.

 

In your experience have you seen similar problems arising from the incorrect positioning of an electrode? 

I am aware that in DBS the precise positioning of the electrodes is crucial in achieving the optimal clinical outcome and would appreciate your comments

.

 Thank You Robert Cartman

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It is sometimes a consequence of medication optimization, sometimes a misplaced lead and sometimes both.  When the leads are both in the correct location you may for example experience less off time, less sweating, and a better response.  Sometimes the lead can be too  shallow, but still hit the correct fibers and have a pretty good response.  Finally, sometimes simply moving doses of sinemet closer together to avoid wearing off and titrating to the right dose after DBS can eliminate off time and sweating.  Also nausea can sometimes be addressed by adding lodosyn or domperidone.

 

These are some suggestions.

 

We generally run thresholds for benefit and side effect at each contact on each DBS lead and attempt reprogramming.  We also image the leads and see the position.  Finally we check standardized scales in each medication/DBS condition.  This information can guide troubleshooting and decision making.

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It is sometimes a consequence of medication optimization, sometimes a misplaced lead and sometimes both.  When the leads are both in the correct location you may for example experience less off time, less sweating, and a better response.  Sometimes the lead can be too  shallow, but still hit the correct fibers and have a pretty good response.  Finally, sometimes simply moving doses of sinemet closer together to avoid wearing off and titrating to the right dose after DBS can eliminate off time and sweating.  Also nausea can sometimes be addressed by adding lodosyn or domperidone.

 

These are some suggestions.

 

We generally run thresholds for benefit and side effect at each contact on each DBS lead and attempt reprogramming.  We also image the leads and see the position.  Finally we check standardized scales in each medication/DBS condition.  This information can guide troubleshooting and decision making.

Thank you for your quick response.

As a consequence of the electrode being 'high and lateral', as opposed to being in the optimal position, would the programmer need a higher level of  amplitude to achieve a 'pretty good response', thereby increasing the likelyhood of negative side effects? 

Robert Cartman  

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Good luck, and let us know if we can be of any further help in sorting this out.

 

Here is a recent abstract on the topic of troubleshooting DBS.

 

 

Parkinsonism Relat Disord. 2008 Nov;14(7):532-8. doi: 10.1016/j.parkreldis.2008.01.001. Epub 2008 Mar 5.
A case-based review of troubleshooting deep brain stimulator issues in movement and neuropsychiatric disorders.
Source

Department of Neurology and Neurosurgery, Movement Disorders Center, McKnight Brain Institute, Gainesville, FL 32610, USA. okun@neurology.ufl.edu

Abstract
OBJECTIVE:

To review the spectrum of problems that can occur in the DBS patient and to suggest potential troubleshooting tips for identification and management of DBS related issues.

BACKGROUND:

Deep brain stimulation (DBS) has become commonplace for the treatment of medication-refractory neurological disorders. There remains no consensus on the best practices for screening, surgical techniques, and post-operative care. There are few experienced DBS programmers and scarce resources available describing approaches for troubleshooting DBS problems.

METHODS:

We present a case-based review that offers practical tips for the management and troubleshooting of difficult to manage DBS cases. We present 10 cases to demonstrate common issues encountered in DBS management.

RESULTS:

There are many important difficulties that may be encountered with DBS devices, and practitioners should be aware of these potential problems, as well as rational management solutions. The following areas should be emphasized as potential causes of difficulties: a non-ideal initial DBS candidate, inadequate multidisciplinary team care, failure of perceived expectations, DBS procedural complication, hardware complication, suboptimal lead placement, programming, access to care, disease progression, and tolerance/habituation.

CONCLUSION:

Neurologists seeing DBS patients should become familiar with issues involved in difficult to manage DBS cases. Many "DBS failures" are currently treatable by appropriate medicine, programming, and surgical approaches.

 

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With regard to my wife and 'tremor prodominant' parkinsons, the STN was selected as the site for DBS because successful stimulation of this area evidently also increases the effectiveness of the Levadopa as well as controlling tremor. 

However if the lead placement is suboptimal (as in the case of my wife) would that potentially reduce the benefits that could be gained in terms of increasing the effectiveness of the Levadopa.

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I would say that STN DBS does not necessarily increase the effectiveness of levodopa.  What happens in many cases with that particular target is that the patient achieves more on time overall.  This can be from successful stimulation, but also is achieves from the balance with medications.  In cases of bilateral STN DBS in many cases the optimal response is achieved by reducing medication some, and thereby avoiding dyskinesias that may result from stimulation of that target.

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Thanks for response Doctor, in your clinic do you generally see the need to increase stimulation levels as the patient's condition deteriorates.

The reason I ask that is because, in my wife's case whereby the left electrode is sub optimal, she is already on 3 volts and also on the right electrode she is on 2.9 volts (but we do not know if this electrode is sub optimal).

We are concerned that as she deteriorates the level of stimulation will have to be increased to compensate and control her tremor. 

Given that she is only 62 and can expect to live into her 80s would you advise that the electrode be re positioned if that was an option.

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I cannot advise repositioning an electrode over the internet.  I can only say that a careful interdisciplinary evaluation and shared decision making process with an experienced team can lead you to the right solution in your case.

 

In general the approach of trying to continuously increase voltage to control tremor has not been recommended.  Parkinson tremor should stay suppressed with DBS long term when the lead is optimally located.  Essential tremor in many cases however, will progress.

 

In general patients and doctors who continue to change DBS parameters at every visit after the first 6-12 months of therapy may be doing their patients a disservice.  The first several months should be used to find the right parameters and most of the other visits should focus on medications and interdisciplinary therapies.

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