Where are we with Deep Brain Stimulation? Ben Wright Consultant - - PowerPoint PPT Presentation

Where are we with Deep Brain Stimulation?

Ben Wright Consultant Neurologist, UHB benjamin.wright@uhb.nhs.uk

Job code: ON/JUN18/UK/259; Date of preparation: June 2018 This meeting is sponsored by Bial Pharma UK.

The views expressed in this presentation are those of the speaker and not necessarily those

• f the meeting sponsor

Declaration of Interests

• Abbvie

Contribution to cost of event Consultancy fee

• Bial

Consultancy fee

• Britannia

Contribution to cost of event Consultancy fee

• Ipsen

Contribution to cost of event

• Medtronic

Contribution to cost of event

• Profile Pharma

Fee for service

• UCB

Fee for service

Content

• How did it develop?
• How does it work?
• Whom does it work for?
• What’s next?

How did DBS develop?

Electrical Stimulation

• 2500 BC

Ancient Egypt

• 1-50 AD

Scribonius Largus

• 1874

Roberts Bartholow

Location targeting

• 1909

Horsley

• 1937

Bucy & Case

• 1939

Meyers

• 1947

Spiegel & Wycis

• 1949

Leskell

• 1952

Cooper

• 1954

Hassler & Riechert

• 1961

Albe-Fessard

• 1960

Hassler

• 1963

Bekthereva

• 1965

Sem-Jacobsen

How did DBS develop?

Levodopa

• 1957

Carlsson

• 1961

Hornykiewicz & Birkmayer

• 1967

Cotzias

• 1969

Yahr Technology improvements

• CT
• MRI
• Battery

How did DBS develop?

• 1987

Benabid – Thalamic DBS

• 1995

Limousin – STN DBS

Okun NEJM 2012

How does it work?

• Rate model
• Modulation model
• Cellular perspective
• Neuroprotection?

Whom to treat?

Consider deep brain stimulation for people with advanced Parkinson's disease whose symptoms are not adequately controlled by best medical therapy

NICE guideline (NG71) 2017

• Levodopa responsive

symptoms

• Dyskinesia
• On-Off fluctuations
• Tremor
• Levodopa unresponsive

symptoms

• Dementia
• Uncontrolled psychiatric

disease

• No caregiver
• Operative risk

Who? Who not?

Patient video

When?

Author DBS Target Trial N Study Duration Age Disease Duration

Deuschl 2006 STN Randomised control 78 6 months 60.5 +/- 7.4 13.0 Okun 2012 STN Open label Randomised control 136 3 months 60.6 +/- 8.3 12.1 +/- 4.9 Schüpbach 2007 STN Randomised control 10 18 months 48.4 +/- 3.3 7.2 +/- 1.2 Schüpbach 2013 STN Randomised control 124 2 years 52.0 +/- 6.3 7.5 +/- 3.0 Weaver 2009 Follett 2010 STN GPi Randomised control 121 6 months 24 months 62.4 +/- 8.8 10.8 +/- 5.4 Okun 2009 STN GPi Randomised control 45 7 months 60.0 +/- 8.2 12.9 +/- 3.8 Esselink 2004 STN Pallidotomy Randomised control 34 6 months 61 (55-66) 62 (57-68) 12 (9-17) 11 (9-16) Williams 2010 STN GPi Open label Randomised control 183 12 months 59 (37-79) 11.5 (1-30) Fraix 2006 STN Prospective cohort 95 12 months 57 +/- 8 14 +/- 5 Perriol 2006 STN Prospective cohort 58 12 months 59 (45 – 73) 14 (4 – 25) Tir 2007 STN Prospective cohort 103 12 months 58.7 +/- 8.2 13.6 +/- 4.4 Derost 2007 STN Prospective cohort 87 2 years 57.4 +/- 4.9 68.8 +/- 2.8 11.5 +/- 0.6 12.4 +/- 0.7 Ory-Magne 2007 STN Prospective cohort 45 2 years 60 +/- 9 13.5 +/- 3.6

Average 59.1 11.8

Where next?

Where next?

Location targeting

• Improved imaging

Adapted from Coenen et al Acta Neurochirurgica 2017

Where next?

Location targeting

• Improved imaging
• Local field recording

Adapted from Accola et al Brain 2016

Where next?

Location targeting

Adapted from Martens Clinical Neurophys 2011

• Improved imaging
• Local field recording
• Current steering

Where next?

Refine control

• Irregular stimulation
• Adaptive stimulation
• External feedback

Adapted from Tinkhauser et al. Brain 2017

Where next?

Where next?

Target area Connectivity Disease state Ideal state

Thank you

benjamin.wright@uhb.nhs.uk