Deep brain stimulation

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Stereotaxic device for placing a stimulation electrode
Illustration of the probes in the brain in an x-ray of the skull

The deep brain stimulation ( DBS ; English DBS , Deep Brain Stimulation ') is basically reversible, neurosurgical intervention in the brain, certain for the treatment of neurological diseases such as the Parkinson's disease is approved worldwide. Colloquially, the term brain pacemaker is also used, which was coined in the early 1970s by the Spanish scientist José Delgado and which emphasizes the technological relationship with the pacemaker.

DBS is approved in the EU for essential tremor (since 1995), for Parkinson's disease (1998), for dystonia (2003), obsessive-compulsive disorder (2009), and epilepsy (2010) and is associated with considerable improvements in quality of life.

Reconstruction of deep brain stimulation electrodes. Shown are the subthalamic nucleus (orange), the ruber nucleus (green), the substantia nigra (yellow), the internal (cyan) and external (blue) part of the pallidum and the striatum (red). Structural fiber tracts that run through a modeled stimulation volume are shown color-coded, the cortical areas in which they open are shown in transparent colors.
Two deep brain stimulation electrodes targeting the subthalamic nucleus for the treatment of Parkinson's disease. An electric field with monopolar stimulation of 3V on the second lowest contact is shown. White arrows represent the E-field vector. Calculation with finite element method using Lead-DBS software.

application areas

Movement disorders

The method is mainly used in the treatment of various movement disorders , such as the symptoms of Parkinson's disease , Tourette's syndrome , essential tremor , tremor in multiple sclerosis, and dystonia .

Deep brain stimulation and its areas of application are the subject of current research:

  • Parkinson's disease : most common area of ​​application for deep brain stimulation. Researchers at Forschungszentrum Jülich and the University of Cologne are working on the development of a brain pacemaker that will not only suppress Parkinson's symptoms, but correct them and allow the brain to function normally again. For this idea they received the Erwin Schrödinger Prize in 2005 .
  • Tourette syndrome : The implantation of a brain pacemaker can partially relieve patients with Tourette syndrome from tics. This is confirmed by a study by British and Italian neurosurgeons.

depression

  • The use of deep brain stimulation in depression is in the experimental stage. Positive results were shown in very small groups of therapy-resistant patients with stimulation of the subgenual area ( field 25. Brodmanns ) and the nucleus accumbens . Thomas E. Schlaepfer and Volker A. Coenen achieved good results by positioning the electrode on the nerve cord that connects the deep-lying brain stem to the frontal cortex with the subgenual and nucleus accumbens structures.

Further areas of application

functionality

Structures of the basal ganglia

How deep brain stimulation works in detail has not yet been clarified. However, the mode of action is the subject of intense research and four general theories are currently being discussed:

  • Functional block of the axons through depolarization
  • Synaptic inhibition
  • Depletion of neurotransmitters due to continued excitation of neurons
  • The stimulation-induced change in the pathological activity of the neural network of the brain

A small battery-powered and chip-controlled pulse generator serves as a control element, which is used under the skin of the chest muscles or on the upper abdomen. The electrodes are inserted through small holes in the top of the skull into the target region of the basal ganglia in the left and right hemispheres of the brain.

In the treatment of patients with advanced Parkinson's disease, the subthalamic nucleus or the medial globus pallidus is targeted , in the case of essential tremor the ventral thalamus and in dystonia the globus pallidus. A study by the University Clinics of Cologne and Bonn on the effectiveness in depression examines the stimulation of the nucleus accumbens .

surgery

Around 400 brain pacemakers are implanted every year in around 30 clinics in Germany. The implantation is reversible.

For chronic brain stimulation, one or two thin electrodes are implanted into the patient with a stereotactic target device, which are connected to a pulse generator in the chest or upper abdomen via subcutaneous cables. This pulse generator continuously sends electrical impulses to the target region in the brain, which - depending on the current frequency - can either be deactivated or stimulated.

The operation takes place in two steps. In the first, small holes are drilled in the patient's skull in a stereotactic operation , through which the electrodes are inserted into the brain. The patient is usually fully conscious. This is the only way to check the effectiveness of the individual electrodes and thus their exact position with the help of test stimulations. The pulse generator (brain pacemaker) is implanted either during this procedure or in a second, shorter operation the following day.

Originally, four contacts were used on each side of the brain. At the end of 2010, a brain pacemaker model with eight contacts on each side of the brain was implanted for the first time at Cologne University Hospital. A higher number of electrodes in the brain should make the device more efficient and have fewer side effects on other brain regions.

Function of the pacemaker system

The pacemaker system essentially consists of three components, the electrodes , the extension and the neurostimulator (pacemaker). The principle of the brain pacemaker represents a further development of the heart pacemaker.

  • Electrodes are thin, flexible wires made of titanium with metal contacts on the tip. The number of contacts via which the impulses can be delivered to the corresponding brain areas varies depending on the manufacturer.
  • The extension is a thin, insulated wire that is led under the skin from the head down to the control device (neurostimulator). It connects the electrodes in the head with the pacemaker (neurostimulator).
  • The neurostimulator includes the battery and allows programming of the stimulation parameters. It is as large as 1.5 to 2 matchboxes and is usually implanted under the collarbone or the costal arch, depending on the patient's wishes. This is where the electrical impulses required for stimulation are generated.
  • With the help of a programming device, the settings of the neurostimulator can be checked and adjusted from outside the body. After the procedure, some patients can be given a small patient handheld device to take home. This can help patients to influence their therapy individually. It can e.g. B. functions controlled and the stimulation z. B. be switched on or off overnight. In most cases, however, the neurostimulator will remain on permanently.

Since deep brain stimulation was approved for essential tremor in 1995, there have been many technical innovations that are promoted by competition from several providers. Among other things, the brain pacemaker system is now often compatible with magnetic resonance imaging examinations.

Side effects

A successful operation can, however, be followed by temporary or long-lasting dysarthria or mostly temporary manic behavior with inappropriately elevated mood, abnormal increase in drive, material wasteful behavior and severe impairment of personal productivity. Prospective controlled and randomized studies in recent years have shown the continued effectiveness of the therapy method in the individual course of the disease: Not only symptoms such as tremors (tremor), rigidity (rigidity) and lack of exercise (bradykinesia) are improved, but also demonstrably the quality of life in a holistic way.

Some of the patients become depressed after the deep brain stimulation despite the improvement in the motor disorders.

Ethical discussion

Since the exact mode of action in the brain is unknown and it is possible to influence mood and behavior (depression, obsessive-compulsive disorder, mania), deep brain stimulation is also the subject of ethical discussions. In principle, it cannot be ruled out that deep brain stimulation can also improve the performance of the human brain (so-called neuro-enhancement ). In this respect, it is no longer just a matter of therapy, but of ways of improving your own brain, e.g. B. also for your own competitive or learning advantage. The National Ethics Council held a discussion on neuroimplants in January 2006. In terms of self-determination, it was seen as advantageous that the deep brain stimulation is reversible and the neurostimulator can be switched off at any time.

literature

  • TE Schläpfer, BH Bewernick: Deep brain stimulation for psychiatric disorders - state of the art. In: Advances and Technical Standards in Neurosurgery. 34, 2009, pp. 37-57.
  • Ralph Erbacher: Analysis of the influence of the stimulation frequency on the cerebral blood flow at rest in patients with essential tremor and deep brain stimulation in the VIM thalamus. An H2-15O PET study. Dissertation . Technical University of Munich, 2003.
  • Isabella Maria Henriette von Falkenhayn: Investigations of the regional cerebral blood flow with deep brain stimulation for the therapy of akinesia in Parkinson's disease. Dissertation. Technical University of Munich, 2000
  • Eleni-Ioanna Anthogalidis: Standardized documentation sheet for endoscopic stereotactic operations in neurosurgery. Görich & Weiershäuser, Marburg 1998, ISBN 3-89703-224-4 .
  • Jose MR Delgado: Brain Pacemaker. Direct information through electrodes. Ullstein, Frankfurt am Main 1971, ISBN 3-550-07024-1 .
  • Helmut Dubiel : Deep in the brain. Kunstmann Verlag, Munich 2006, ISBN 3-88897-451-8 .
  • Peter A. Tass, Milan Majtanik: Long-term anti-kindling effects of desynchronizing brain stimulation: a theoretical study. In: Biological Cybernetics. Vol. 94, no. 1, 2006, pp. 58-66. doi: 10.1007 / s00422-005-0028-6
  • Peter A. Tass, Joachim Klosterkötter, Frank Schneider, Doris Lenartz, Anastasios Koulousakis, Volker Sturm: Obsessive-compulsive disorder: Development of demand-controlled deep brain stimulation with methods from stochastic phase resetting. In: Neuropsychopharmacology. 28, 2003, pp. 27-34. doi: 10.1038 / sj.npp.1300144
  • Christian Hauptmann, Oleksandr Popovych, Peter A. Tass: Effectively desynchronizing deep brain stimulation based on a coordinated delayed feedback stimulation via several sites: a computational study. In: Biological Cybernetics. Vol. 93, No. 6, 2005, pp. 463-470. doi: 10.1007 / s00422-005-0020-1
  • Günther Deuschl et al .: A randomized trial of deep-brain-stimulation for Parkinson's disease. In: The New England Journal of Medicine . 355 (9), 2006, pp. 896-908. doi: 10.1056 / NEJMoa060281
  • Jens Kuhn, Theo OJ Gründler, Doris Lenartz, Volker Sturm, Joachim Klosterkötter, Wolfgang Huff: Deep brain stimulation in psychiatric diseases. In: Deutsches Ärzteblatt . 107 (7), 2010, pp. 105-13. doi: 10.3238 / arztebl.2010.0105
  • Matthias Becker: Risk of neuroimplants: brain operations on awake patients. In: Telepolis special Mensch +: Upgrade revolution for Homo sapiens. Heise, 2012 ( abridged version in Spiegel Online . March 11, 2012)

Web links

Individual evidence

  1. ↑ Andreas Horn, Andrea A. Kühn: Lead-DBS: A toolbox for deep brain stimulation electrode localizations and visualizations . In: NeuroImage . No. 107 . Elsevier, February 2015, p. 127–135 , doi : 10.1016 / j.neuroimage.2014.12.002 , PMID 25498389 (English).
  2. ↑ http://www.lead-dbs.org
  3. ↑ Long term deep brain stimulation in Tourette syndrome. In: Ärzteblatt. October 28, 2009 aerzteblatt.de Retrieved October 10, 2015.
  4. ↑ Targeted out of sync. In: Handelsblatt online. November 21, 2006.
  5. ↑ M. Porta, A. Brambilla et al.: Thalamic deep brain stimulation for treatment-refractory Tourette syndrome. In: Neurology. 73, 2009, pp. 1375-1380.
  6. ^ TE Schlaepfer, K. Lieb: Deep brain stimulation for treatment of refractory depression. In: Lancet. 366 (9495), Oct 2005, pp. 1420-1422. PMID 16243078 .
  7. ↑ TE Schläpfer, BH Bewernick: . Deep Brain Stimulation for Psychiatric Disorders - State of the Art In: Advances and technical standards in neurosurgery. 34, 2009, pp. 37-57. PMID 19368080 .
  8. ↑ HS Mayberg, AM Lozano, V. Voon, HE McNeely, D. Seminowicz, C. Hamani, JM Schwalb, SH Kennedy: Deep brain stimulation for treatment-resistant depression. In: Neuron. 45 (5), 2005. PMID 15748841 .
  9. ^ TE Schlaepfer, MX Cohen, C. Frick, M. Kosel, D. Brodesser, N. Axmacher, AY Joe, M. Kreft, D. Lenartz, V. Sturm: Deep Brain Stimulation to Reward Circuitry Alleviates Anhedonia in Refractory Major Depression . In: Neuropsychopharmacology . 33 (2), Jan 2008, pp. 368-377. PMID 17429407
  10. ↑ BH Bewernick, R. Hurlemann, A. Matusch, S. Kayser, C. Grubert, B. Hadrysiewicz, N. Axmacher, M. Lemke, D. Cooper Mahkorn, MX Cohen, H. Brockmann, D. Lenartz, V Sturm, TE Schlaepfer: Nucleus Accumbens Deep Brain Stimulation Decreases Ratings of Depression and Anxiety in Treatment-Resistant Depression. In: Biological Psychiatry. 67, 2010, pp. 110-116. PMID 19914605 .
  11. ↑ Electric shocks provide lasting relief from severe depression. In: time online. April 8, 2013.
  12. ^ Rapid Effects of Deep Brain Stimulation for Treatment-Resistant Major Depression. In: Biological Psychiatry. Volume 73, Issue 12, June 15, 2013, pp. 1204-1212
  13. ^ S1 guideline for cluster headaches and trigemino-autonomic headaches of the German Society for Neurology (DGN). In: AWMF online (as of 2015)
  14. ^ M. Leone, A. Franzini, G. Broggi, G. Bussone: Hypothalamic stimulation for intractable cluster headache: long-term experience. In: Neurology. 67 (1), 2006, pp. 150-152. PMID 16832097 .
  15. ↑ Doctors dare to perform brain operations on awake patients. In: Spiegel online. June 6, 2012.
  16. ↑ a b Tanja Krämer: Is the controlled personality coming? In: Spectrum of Science. 9/07, p. S42 ff.
  17. ↑ CC McIntyre, M. Savasta, L. Kerkerian-LeGroff, JL Vitek: Uncovering the mechanism (s) of action of deep brain stimulation: activation, inhibition, or both. In: Clinical Neurophysiology. 115, 2006, pp. 1239-1248.
  18. ↑ Bettina H Bewernick, René Hurlemann, Andreas Matusch, Sarah Kayser, Christiane Grubert, Barbara Hadrysiewicz, Nikolai Axmacher and others: Nucleus Accumbens Deep Brain Stimulation Decreases Ratings of Depression and Anxiety in Treatment-Resistant Depression. In: Biological psychiatry. 67, no. 2, 2010. PMID 19914605
  19. ↑ New brain pacemaker implanted for the first time. on: heilpraxisnet.de , November 10, 2010.
  20. ↑ M. Ulla et al .: Manic behavior induced by deep-brain stimulation in Parkinson's disease: evidence of substantia nigra implication? In: Journal of Neurology, Neurosurgery, and Psychiatry. 77, 2006, pp. 1363-1366 PMID 17110749 .
  21. ↑ Helmut Dubiel : Deep in the brain . Kunstmann Verlag, Munich 2006.
  22. ↑ M. Synofzyk, TE Schlaepfer: Stimulating personality: Ethical criteria for deep brain stimulation in psychiatric patients and for enhancement purposes. In: J. Biotechnol. 3 (12), 2008, pp. 1511-1520. PMID 19072907
  23. ↑ Sabine Müller, Markus Christen: Possible personality changes through deep brain stimulation in Parkinson's patients. ( Memento of the original from February 22, 2014 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. In: Neurology. 29 (11), 2010, pp. 779-783. @1@ 2Template: Webachiv / IABot / www.schattauer.de
  24. ↑ See, among other things, deep brain stimulation: “With brain stimulation you sometimes come up against ethical limits” ( Memento from November 4, 2014 in the web archive archive.today ) April 22, 2013.