{"id":1008,"date":"2017-05-05T17:25:52","date_gmt":"2017-05-05T17:25:52","guid":{"rendered":"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/?p=1008"},"modified":"2017-05-05T17:25:52","modified_gmt":"2017-05-05T17:25:52","slug":"deep-brain-stimulation-targeting-neurosurgery-part-iii-iii","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/2017\/05\/05\/deep-brain-stimulation-targeting-neurosurgery-part-iii-iii\/","title":{"rendered":"Deep Brain Stimulation Targeting in Neurosurgery, Part III of III"},"content":{"rendered":"<div id=\"attachment_678\" style=\"width: 135px\" class=\"wp-caption alignright\"><a href=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/08\/AU000_bbelcher.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-678\" class=\"size-full wp-image-678\" src=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/08\/AU000_bbelcher.jpg\" alt=\"\" width=\"125\" height=\"150\" \/><\/a><p id=\"caption-attachment-678\" class=\"wp-caption-text\">Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.<\/p><\/div>\n<p>This is the final part of a three-part series on deep brain stimulation (DBS) targeting designed for providers who lack an intimate level of knowledge and\/or experience with this subject matter. In\u00a0<a href=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/2017\/02\/24\/deep-brain-stimulation-targeting-neurosurgery-part-iii\/\"><strong>Part I<\/strong><\/a>, I discussed the ventralis intermedius (Vim) target as well as an overview of DBS, equipment, and programming, and <strong><a href=\"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-admin\/post.php?post=961&amp;action=edit\">Part II<\/a><\/strong> covered the globus pallidus internus (GPi). This final part is a review of the subthalamic nucleus (STN), the default target in some institutions. There is more scientific literature about the STN than about other targets [1], but this is changing.<\/p>\n<p style=\"text-align: center\"><strong><u>Subthalamic Nucleus (STN)<\/u><\/strong><\/p>\n<p><span style=\"color: #0000ff\"><strong>Where is it\u00a0located?<\/strong><\/span><\/p>\n<p>The STN is located just below the thalamus at the posterior limb of the internal capsule, medial to cranial nerve III, and inferior to the substantia nigra.<\/p>\n<p><span style=\"color: #0000ff\"><strong><a href=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-anatomic.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-medium wp-image-1006\" src=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-anatomic-300x290.jpg\" alt=\"\" width=\"300\" height=\"290\" srcset=\"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-anatomic-300x290.jpg 300w, https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-anatomic-25x25.jpg 25w, https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-anatomic-32x32.jpg 32w, https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-anatomic.jpg 453w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>Indication for\u00a0Targeting<\/strong>:<\/span><\/p>\n<ul>\n<li><em>Parkinson\u2019s Disease (PD)<\/em>\n<ul>\n<li>Stimulation of the STN treats the cardinal motor symptoms of PD more effectively than GPi or Vim.<\/li>\n<li>Patients with severe \u201cON\/OFF\u201d fluctuations tend to do better with STN lead placement.<\/li>\n<li>STN placement provides the best chance of achieving post surgical medication reduction.<\/li>\n<li>The STN, a smaller target than the GPi, often requires lower voltage to achieve symptom relief, leading to less frequent battery changes. If a patient is young and may require several battery changes over their lifetime, this may be a secondary consideration after optimal symptom relief. Of note, there is a rechargeable battery on the market that may negate this consideration in some patients.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Cautions:<\/strong><\/p>\n<ul>\n<li>If dystonia is present, stronger consideration is usually given to GPi placement over STN.<\/li>\n<li>Psychiatric comorbidities in patients can be exacerbated with stimulation around the STN. Our patients undergo neuropsychological testing prior to target selection to mitigate this risk.<\/li>\n<\/ul>\n<p><span style=\"color: #0000ff\"><strong>Adverse side effects of stimulation based on location of electrode in relation to optimal\u00a0placement\u00a0[2]:<\/strong><\/span><\/p>\n<p><strong>Too lateral<\/strong>\u00a0\u2013 With stimulation of the motor and frontal eye fibers of the internal capsule, the patient would experience muscle contractions, dysarthria, and contralateral gaze deviation.<\/p>\n<p><strong>Too medial<\/strong>\u00a0\u2013 Diplopia, eye deviation, sweating, nausea, depression, and personality changes can all be a consequence of stimulating medial structures such as the nerve roots of CNIII, the red nucleus, or the ventromedial portion of the STN.<\/p>\n<div id=\"attachment_1007\" style=\"width: 310px\" class=\"wp-caption alignright\"><a href=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-effective-placement.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1007\" class=\"size-medium wp-image-1007\" src=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-effective-placement-300x170.jpg\" alt=\"\" width=\"300\" height=\"170\" srcset=\"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-effective-placement-300x170.jpg 300w, https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2017\/05\/STN-effective-placement.jpg 676w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-1007\" class=\"wp-caption-text\">Green, STN. Red, Red nucleus. Purple, Oculomotor nucleus of CNIII. Blue, medial lemniscal pathway.<\/p><\/div>\n<p><strong>Too posterior<\/strong>\u00a0\u2013 With stimulation of the medial lemniscus, the patient will experience paresthesias.<\/p>\n<p><strong>Too anterior<\/strong>\u00a0\u2013 The patient will experience muscle contractions and autonomic symptoms such as panicky feelings or sweating due to stimulation of the hypothalamus or motor fibers of the internal capsule.<\/p>\n<p><strong>Too superior<\/strong>\u00a0\u2013 No effect on tremor<\/p>\n<p><strong>Too deep<\/strong>\u00a0\u2013 Mood changes and muscle contractions due to stimulation of the substantia nigra or the internal capsule<\/p>\n<p>&nbsp;<\/p>\n<p><strong>References<\/strong><\/p>\n<ol>\n<li>Deep Brain Stimulation Management. William J. Marks, Jr. Cambridge University Press 2010<\/li>\n<li>DBS Anatomy &amp; Side Effects. A Presentation by Kirk Finnis, PhD. Medtronic.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p><a href=\"https:\/\/secure.jwatch.org\/registerm?cpc=JWATCH&amp;promo=OJFOBLOG&amp;step=1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-925\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/03\/hivJWAd540x250.jpg\" alt=\"Register Now for more NEJM Journal Watch Content\" width=\"540\" height=\"250\" \/><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>This is the final part of a three-part series on deep brain stimulation (DBS) targeting designed for providers who lack an intimate level of knowledge and\/or experience with this subject matter. In\u00a0Part I, I discussed the ventralis intermedius (Vim) target as well as an overview of DBS, equipment, and programming, and Part II covered the [&hellip;]<\/p>\n","protected":false},"author":1259,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[20,29],"tags":[382,383,413],"class_list":["post-1008","post","type-post","status-publish","format-standard","hentry","category-education","category-patient-care","tag-deep-brain-stimulation","tag-parkinsons-disease","tag-subthalamic-nucleus"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/posts\/1008","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/users\/1259"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/comments?post=1008"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/posts\/1008\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/media?parent=1008"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/categories?post=1008"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/tags?post=1008"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}