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Philip A Starr - One of the best experts on this subject based on the ideXlab platform.
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hemorrhage detection and incidence during magnetic resonance guided Deep Brain Stimulator implantations
Stereotactic and Functional Neurosurgery, 2017Co-Authors: Alastair J. Martin, Philip A Starr, Jill L Ostrem, Paul S. LarsonAbstract:Background/aims Intraoperative magnetic resonance imaging (iMRI) is increasingly used to implant Deep Brain Stimulator (DBS) electrodes. The approach has the advantages of a high targeting accuracy, minimization of Brain penetrations, and allowance of implantation under general anesthesia. The hemorrhagic complications of iMRI-guided DBS implantation have not been studied in a large series. We report on the incidence and characteristics of hemorrhage during these procedures. Methods Hemorrhage incidence was assessed in a series of 231 iMRI procedures (374 electrodes implanted). All patients had movement disorders and the subthalamic nucleus or the globus pallidus internus was typically targeted. Hemorrhage was detected with intra- or postoperative MRI or postoperative computed tomography. Hemorrhage was classified based on its point of origin and clinical impact. Results Hemorrhage and symptomatic hemorrhage were detected during 2.4 and 1.1% of electrode implantations, respectively. The hemorrhage origin was subdural/subarachnoid (n = 3), subcortical (n = 5), or Deep (n = 1). Factors that contributed to hemorrhage included unintentional crossing of a sulcus and resistance at the pial membrane, which produced cortical depression and a rebound hemorrhage. Delayed hemorrhage occurred in 2 patients and was attributed to premature reintroduction of anticoagulation therapy or air intrusion into the cranial cavity. Conclusions Hemorrhage was readily apparent on intraoperative imaging, and hemorrhage rates for iMRI-guided DBS implantations were comparable to those for conventional implantation approaches.
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oscillations in sensorimotor cortex in movement disorders an electrocorticography study
Brain, 2012Co-Authors: Andrea Crowell, Jill L Ostrem, Elena S Ryapolovawebb, Nicholas B Galifianakis, Shoichi A Shimamoto, Philip A StarrAbstract:Movement disorders of basal ganglia origin may arise from abnormalities in synchronized oscillatory activity in a network that includes the basal ganglia, thalamus and motor cortices. In humans, much has been learned from the study of basal ganglia local field potentials recorded from temporarily externalized Deep Brain Stimulator electrodes. These studies have led to the theory that Parkinson's disease has characteristic alterations in the beta frequency band (13–30 Hz) in the basal ganglia–thalamocortical network. However, different disorders have rarely been compared using recordings in the same structure under the same behavioural conditions, limiting straightforward assessment of current hypotheses. To address this, we utilized subdural electrocorticography to study cortical oscillations in the three most common movement disorders: Parkinson's disease, primary dystonia and essential tremor. We recorded local field potentials from the arm area of primary motor and sensory cortices in 31 subjects using strip electrodes placed temporarily during routine surgery for Deep Brain Stimulator placement. We show that: (i) primary motor cortex broadband gamma power is increased in Parkinson's disease compared with the other conditions, both at rest and during a movement task; (ii) primary motor cortex high beta (20–30 Hz) power is increased in Parkinson's disease during the ‘stop’ phase of a movement task; (iii) the alpha–beta peaks in the motor and sensory cortical power spectra occur at higher frequencies in Parkinson's disease than in the other two disorders; and (iv) patients with dystonia have impaired movement-related beta band desynchronization in primary motor and sensory cortices. The findings support the emerging hypothesis that disease states reflect abnormalities in synchronized oscillatory activity. This is the first study of sensorimotor cortex local field potentials in the three most common movement disorders. * Abbreviations : M1 : primary motor cortex S1 : primary sensory cortex UPDRS : Unified Parkinson's Disease Rating Scale
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Implantation of Deep Brain Stimulator Electrodes Using Interventional MRI
Neurosurgery clinics of North America, 2009Co-Authors: Philip A Starr, Alastair J. Martin, Paul S. LarsonAbstract:The authors describe a method for placement of Deep Brain Stimulator electrodes using interventional MRI in conjunction with a skull-mounted aiming device (Medtronic Nexframe). This approach adapts the procedure to a standard-configuration 1.5-T diagnostic MRI scanner in a radiology suite. Preoperative imaging, device implantation, and postimplantation MRI are integrated into a single procedure performed under general anesthesia, providing real-time, high-resolution magnetic resonance confirmation of electrode position. The method is conceptually simpler than the current standard technique for Deep Brain Stimulator placement, as it eliminates the stereotactic frame, the subsequent requirement for registration of the Brain in stereotactic space, physiologic testing, and the need for patient cooperation. With further technical refinement, the interventional MRI method should improve the accuracy, safety, and speed of Deep Brain Stimulator electrode placement.
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interventional magnetic resonance guidance of Deep Brain Stimulator implantation for parkinson disease
Topics in Magnetic Resonance Imaging, 2008Co-Authors: Alastair J. Martin, Jill L Ostrem, Paul S. Larson, Philip A StarrAbstract:Deep Brain stimulation is increasingly being applied to movement disorders, and other novel applications are emerging. The therapy requires precise localization of the stimulation electrode at specific target sites in Deep Brain structures. Conventional means of implantation rely on stereotactic approaches, which lack sufficient targeting accuracy and therefore are supported by invasive physiological mapping. We review the use of interventional magnetic resonance image guidance for the implantation of Deep Brain Stimulator electrodes in patients with moderate to advanced Parkinson disease. The methodologies used in this innovative surgical technique are presented, along with the potential benefits and limitations of such an approach. Targeting accuracies are shown to be within approximately 1 mm of the intended Deep Brain structure and are achieved with a single Brain penetration in most cases. Preliminary evaluation of clinical outcomes indicates comparable results to that achieved with conventional implantation methods, and the technique holds promise for substantially reducing operative durations.
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Deep Brain Stimulator hardware related infections incidence and management in a large series
Neurosurgery, 2008Co-Authors: Karl A Sillay, Paul S. Larson, Philip A StarrAbstract:OBJECTIVE: Device-related infection is a common complication of Deep Brain Stimulator (DBS) implantation. We reviewed the incidence and management of early hardware-related infections in a large series. METHODS: All patients undergoing DBS implantation surgery between 1998 and 2006 at a single institution were entered into a prospectively designed database. After database verification by cross-referencing manufacturer implantation records, a query was performed to include all new Medtronic (Minneapolis, MN) implantations performed with standard operating room technique. Hardware-related infections requiring further surgery were identified, and charts were reviewed to assess the success of lead-sparing partial hardware removal in this group. RESULTS: Four hundred twenty patients received 759 new DBS electrodes and 615 new internal pulse generators for the treatment of movement disorders or pain. Nineteen patients (4.5%) had an early (<6 mo) hardware-related infection requiring further surgery. There were no intracranial infections. Four patients presented with extensive cellulitis or wound dehiscence and were treated with total hardware removal. Fourteen patients presented with more localized infections and were treated by removal of the involved components only, followed by intravenously administered antibiotics. In nine of these patients, partial hardware removal successfully resolved the infection without requiring removal of the DBS electrodes. Wound washout alone was attempted in one patient and failed. CONCLUSION: In a large series of new DBS hardware implantations, the incidence of postoperative hardware-related infection requiring further surgery was 4.5%. When only one device component was involved, partial hardware removal was often successful.
Ali R Rezai - One of the best experts on this subject based on the ideXlab platform.
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accuracy and precision of targeting using frameless stereotactic system in Deep Brain Stimulator implantation surgery
Neurology India, 2014Co-Authors: Mayur Sharma, Milind Deogaonkar, Richard Rhiew, Ali R Rezai, Nicholas M BoulisAbstract:Objectives: To assess the accuracy of targeting using NexFrame frameless targeting system during Deep Brain stimulation (DBS) surgery. Materials and Methods: Fifty DBS leads were implanted in 33 patients using the NexFrame (Medtronic, Minneapolis, MN) targeting system. Postoperative thin cut CT scans were used for lead localization. X, Y, Z coordinates of the tip of the lead were calculated and compared with the intended target coordinates to assess the targeting error. Comparative frame-based data set was obtained from randomly selected 33 patients during the same period that underwent 65 lead placements using Leksell stereotactic frame. Euclidean vector was calculated for directional error. Multivariate analysis of variance was used to compare the accuracy between two systems. Results: The mean error of targeting using frameless system in medio-lateral plane was 1.4 mm (SD ± 1.3), in antero-posterior plane was 0.9 mm (SD ± 1.0) and in supero-inferior plane Z was 1.0 mm (SD ± 0.9). The mean error of targeting using frame-based system in medio-lateral plane was 1.0 mm (SD ± 0.7), in antero-posterior plane was 0.9 mm (SD ± 0.5) and in supero-inferior plane Z was 0.7 mm (SD ± 0.6). The error in targeting was significantly more (P = 0.03) in the medio-lateral plane using the frameless system as compared to the frame-based system. Mean targeting error in the Euclidean directional vector using frameless system was 2.2 (SD ± 1.6) and using frame-based system was 1.7 (SD ± 0.6) (P = 0.07). There was significantly more error in the first 25 leads placed using the frameless system than the second 25 leads (P = 0.0015). Conclusion: The targeting accuracy of the frameless system was lower as compared to frame-based system in the medio-lateral direction. Standard deviations (SDs) were higher using frameless system as compared to the frame-based system indicating lower accuracy of this system. Error in targeting should be considered while using frameless stereotactic system for DBS implantation surgery.
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magnetic resonance imaging safety of Deep Brain Stimulator devices
Handbook of Clinical Neurology, 2013Co-Authors: Chima O Oluigbo, Ali R RezaiAbstract:Magnetic resonance imaging (MRI) has become the standard of care for the evaluation of different neurological disorders of the Brain and spinal cord due to its multiplanar capabilities and excellent soft tissue resolution. With the large and increasing population of patients with implanted Deep Brain stimulation (DBS) devices, a significant proportion of these patients with chronic neurological diseases require evaluation of their primary neurological disease processes by MRI. The presence of an implanted DBS device in a magnetic resonance environment presents potential hazards. These include the potential for induction of electrical currents or heating in DBS devices, which can result in neurological tissue injury, magnetic field-induced device migration, or disruption of the operational aspects of the devices. In this chapter, we review the basic physics of potential interactions of the MRI environment with implanted DBS devices, summarize results from phantom studies and clinical series, and discuss present recommendations for safe MRI in patients with implanted DBS devices.
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dexmedetomidine for Deep Brain Stimulator placement in a child with primary generalized dystonia case report and literature review
Journal of Clinical Anesthesia, 2009Co-Authors: Marco A Maurtua, Ali R Rezai, Juan P Cata, Margarita Martirena, Millind Deogaonkar, Wai Sung, Michelle Lotto, Julie Niezgoda, Armin SchubertAbstract:Dexmedetomidine, which is a relatively selective alpha2-adrenoceptor agonist, is used for sedation and analgesia in intensive care unit patients, during awake craniotomies in pediatric and adult patients, and during magnetic resonance imaging, with minimal depression of respiratory function. The successful use of dexmedetomidine in a pediatric patient undergoing bilateral Deep Brain Stimulator placement for the treatment of generalized dystonia, is presented.
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methods of scalp revision for Deep Brain Stimulator hardware case report
Operative Neurosurgery, 2008Co-Authors: Alejandro M Spiotta, Milind Deogaonkar, Ali R Rezai, Nicholas M Boulis, Mark Bain, Warren C Hammert, Armand LucasAbstract:OBJECTIVE The use of Deep Brain stimulation (DBS) to treat a variety of disorders has expanded and will result in an increasingly larger number of patients and implanted electrodes. Hardware failure can result from malfunction, lead migration, fracture, and infection. Scalp erosion with exposure of underlying hardware can lead to potential infectious complications and is, in itself, a strong indication for explantation of the neurostimulation system. The patient's relief of symptoms after DBS will be limited by hardware-related complications and thus, strategies to revise scalp overlying hardware are important in the widespread application of DBS. CLINICAL PRESENTATION We describe strategies to address complications related to implanted DBS neuroStimulator hardware specifically designed to address breach of the integrity of the scalp over the burr hole site. The aim of these approaches is to treat scalp erosion to allow for the reimplantation of previously explanted, infected hardware, or to treat thinned scalp with threatened erosion and prevent the need to remove exposed hardware that is otherwise functioning. INTERVENTION Two different approaches are presented: 1) a temporoparieto-occipital flap based on the superficial temporal artery with or without scalp expansion, and 2) a scalp fasciocutaneous flap with or without cranioplasty. CONCLUSION Stimulation of various Deep Brain targets helps patients with a wide range of diseases. In the future, with continued refinement, hardware complications can be minimized. Until then, novel approaches need to be developed to save DBS systems and provide symptomatic relief to patients.
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methods of scalp revision for Deep Brain Stimulator hardware technical case report
Neurosurgery, 2008Co-Authors: Alejandro M Spiotta, Milind Deogaonkar, Nicholas M Boulis, Mark Bain, Armand Lucas, Ali R RezaiAbstract:OBJECTIVE: The use of Deep Brain stimulation (DBS) to treat a variety of disorders has expanded and will result in an increasingly larger number of patients and implanted electrodes. Hardware failure can result from malfunction, lead migration, fracture, and infection. Scalp erosion with exposure of underlying hardware can lead to potential infectious complications and is, in itself, a strong indication for explantation of the neurostimulation system. The patient's relief of symptoms after DBS will be limited by hardware-related complications and thus, strategies to revise scalp overlying hardware is important in the widespread application of DBS. CLINICAL PRESENTATION: We describe strategies to address complications related to implanted DBS neuroStimulator hardware specifically designed to address breach of the integrity of the scalp over the burrhole site. The aim of these approaches is to treat scalp erosion to allow for the reimplantation of previously explanted, infected hardware, or to treat thinned scalp with threatened erosion and prevent the need to remove exposed hardware that is otherwise functioning. INTERVENTION: Two different approaches are presented: 1) a temporoparieto-occipital flap based on the superficial temporal artery with or without scalp expansion and 2) a scalp fasciocutaneous flap with or without cranioplasty. CONCLUSION: Stimulations of various Deep Brain targets helps patients with a wide range of diseases. In the future, with continued refinement, hardware complications can be minimized. Until then, novel approaches need to be developed in order to save DBS systems and provide symptomatic relief to patients.
Paul S. Larson - One of the best experts on this subject based on the ideXlab platform.
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hemorrhage detection and incidence during magnetic resonance guided Deep Brain Stimulator implantations
Stereotactic and Functional Neurosurgery, 2017Co-Authors: Alastair J. Martin, Philip A Starr, Jill L Ostrem, Paul S. LarsonAbstract:Background/aims Intraoperative magnetic resonance imaging (iMRI) is increasingly used to implant Deep Brain Stimulator (DBS) electrodes. The approach has the advantages of a high targeting accuracy, minimization of Brain penetrations, and allowance of implantation under general anesthesia. The hemorrhagic complications of iMRI-guided DBS implantation have not been studied in a large series. We report on the incidence and characteristics of hemorrhage during these procedures. Methods Hemorrhage incidence was assessed in a series of 231 iMRI procedures (374 electrodes implanted). All patients had movement disorders and the subthalamic nucleus or the globus pallidus internus was typically targeted. Hemorrhage was detected with intra- or postoperative MRI or postoperative computed tomography. Hemorrhage was classified based on its point of origin and clinical impact. Results Hemorrhage and symptomatic hemorrhage were detected during 2.4 and 1.1% of electrode implantations, respectively. The hemorrhage origin was subdural/subarachnoid (n = 3), subcortical (n = 5), or Deep (n = 1). Factors that contributed to hemorrhage included unintentional crossing of a sulcus and resistance at the pial membrane, which produced cortical depression and a rebound hemorrhage. Delayed hemorrhage occurred in 2 patients and was attributed to premature reintroduction of anticoagulation therapy or air intrusion into the cranial cavity. Conclusions Hemorrhage was readily apparent on intraoperative imaging, and hemorrhage rates for iMRI-guided DBS implantations were comparable to those for conventional implantation approaches.
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e 053 accuracy of flat panel detector ct with integrated navigational software with and without mr fusion for single pass needle placement in a Deep Brain Stimulator phantom in the interventional suite
Journal of NeuroInterventional Surgery, 2015Co-Authors: Marc C Mabray, Paul S. Larson, Sanjit Datta, Prasheel Lillaney, Teri Moore, Sonja Gehrisch, Jason F Talbott, Daniel L CookeAbstract:Purpose Fluoroscopic systems in modern interventional suites have the ability to perform flat panel detector CT (FDCT) and navigational guidance. FDCT data acquired in the interventional suite can be fused with MR data in order to allow navigational guidance towards targets defined on MR. This system could be used for intracranial access or spinal procedure guidance in the interventional suite. We aim to evaluate the accuracy of this system and to report the radiation doses associated with single pass needle placement in a Deep Brain Stimulator (DBS) phantom. Materials and methods An established head phantom with Deep Brain Stimulator lead targets was imaged with an iso-volumetric T2 weighted inversion recovery sequence. The head phantom was placed into a Mayfield Integra headrest system and attached to the procedure table. An 8s FDCT was performed (Siemens, DynaCT) and the CT and MR data sets were automatically fused using the integrated guidance system (iGuide, Siemens). A DBS target was selected on the MR data set. An entry site was selected on the CT data set to visualize the pre-drilled burr hole. The flat panel detector was automatically moved to the correct in-line or “bull’s-eye” projection. The table was manually shimmed to line up the projected targets and entry site. A 10 cm, 19G needle was advanced by hand in a single pass using laser crosshair guidance. Radial error was visually assessed against measurement markers on the target. A second FDCT was performed and the radial error was measured from the center of the planned target to the needle. Air kerma and dose area product (DAP) were recorded. 10 needles were placed using CT-MR fusion and 10 needles were placed without MR fusion, skipping all MR steps and targeting based off of the FDCT. Results Mean target depth was 83.12 mm (SD 20.59). For MR fusion mean visual radial error to the absolute center of the target was 2.55 mm (SD 1.04 mm), mean visual radial error to the 3 mm diameter spherical target was 1.10 mm (SD 0.97 mm), and mean radial error by CT as measured to the planned target point was 2.60 mm (SD 1.05 mm). With CT only targeting, corresponding radial errors were 2.95 mm (1.67 mm), 1.65 mm (1.37 mm), and 3.00 mm (1.68 mm). Mean total air kerma was 122.19 mGy and mean total DAP was 3272 uGy-m2. The operator was only in the room for a mean flouro time of 0.16 min with an air kerma of 1.21 and DAP of 17.28. CT1 had a mean air kerma of 60.39 and DAP of 1624.88 and CT2 had a mean air kerma of 60.58 and DAP 1629.84. In practice CT2 could possibly be omitted. Conclusions Navigational guidance for single pass needle placement in the interventional suite using FDCT with or without fusion to pre-procedural MRI is associated with a radial error of approximately 2.5–3.0 mm at a depth of approximately 80 mm and acceptable radiation to the patient and operator. This system could be used to accurately target sub centimeter intracranial lesions or provide guidance for spinal procedures. Disclosures M. Mabray: None. S. Datta: 5; C; Siemens. P. Lillaney: None. T. Moore: 5; C; Siemens. S. Gehrisch: 5; C; Siemens. J. Talbott: None. P. Larson: None. D. Cooke: None.
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Implantation of Deep Brain Stimulator Electrodes Using Interventional MRI
Neurosurgery clinics of North America, 2009Co-Authors: Philip A Starr, Alastair J. Martin, Paul S. LarsonAbstract:The authors describe a method for placement of Deep Brain Stimulator electrodes using interventional MRI in conjunction with a skull-mounted aiming device (Medtronic Nexframe). This approach adapts the procedure to a standard-configuration 1.5-T diagnostic MRI scanner in a radiology suite. Preoperative imaging, device implantation, and postimplantation MRI are integrated into a single procedure performed under general anesthesia, providing real-time, high-resolution magnetic resonance confirmation of electrode position. The method is conceptually simpler than the current standard technique for Deep Brain Stimulator placement, as it eliminates the stereotactic frame, the subsequent requirement for registration of the Brain in stereotactic space, physiologic testing, and the need for patient cooperation. With further technical refinement, the interventional MRI method should improve the accuracy, safety, and speed of Deep Brain Stimulator electrode placement.
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interventional magnetic resonance guidance of Deep Brain Stimulator implantation for parkinson disease
Topics in Magnetic Resonance Imaging, 2008Co-Authors: Alastair J. Martin, Jill L Ostrem, Paul S. Larson, Philip A StarrAbstract:Deep Brain stimulation is increasingly being applied to movement disorders, and other novel applications are emerging. The therapy requires precise localization of the stimulation electrode at specific target sites in Deep Brain structures. Conventional means of implantation rely on stereotactic approaches, which lack sufficient targeting accuracy and therefore are supported by invasive physiological mapping. We review the use of interventional magnetic resonance image guidance for the implantation of Deep Brain Stimulator electrodes in patients with moderate to advanced Parkinson disease. The methodologies used in this innovative surgical technique are presented, along with the potential benefits and limitations of such an approach. Targeting accuracies are shown to be within approximately 1 mm of the intended Deep Brain structure and are achieved with a single Brain penetration in most cases. Preliminary evaluation of clinical outcomes indicates comparable results to that achieved with conventional implantation methods, and the technique holds promise for substantially reducing operative durations.
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Deep Brain Stimulator hardware related infections incidence and management in a large series
Neurosurgery, 2008Co-Authors: Karl A Sillay, Paul S. Larson, Philip A StarrAbstract:OBJECTIVE: Device-related infection is a common complication of Deep Brain Stimulator (DBS) implantation. We reviewed the incidence and management of early hardware-related infections in a large series. METHODS: All patients undergoing DBS implantation surgery between 1998 and 2006 at a single institution were entered into a prospectively designed database. After database verification by cross-referencing manufacturer implantation records, a query was performed to include all new Medtronic (Minneapolis, MN) implantations performed with standard operating room technique. Hardware-related infections requiring further surgery were identified, and charts were reviewed to assess the success of lead-sparing partial hardware removal in this group. RESULTS: Four hundred twenty patients received 759 new DBS electrodes and 615 new internal pulse generators for the treatment of movement disorders or pain. Nineteen patients (4.5%) had an early (<6 mo) hardware-related infection requiring further surgery. There were no intracranial infections. Four patients presented with extensive cellulitis or wound dehiscence and were treated with total hardware removal. Fourteen patients presented with more localized infections and were treated by removal of the involved components only, followed by intravenously administered antibiotics. In nine of these patients, partial hardware removal successfully resolved the infection without requiring removal of the DBS electrodes. Wound washout alone was attempted in one patient and failed. CONCLUSION: In a large series of new DBS hardware implantations, the incidence of postoperative hardware-related infection requiring further surgery was 4.5%. When only one device component was involved, partial hardware removal was often successful.
Ulrich G. Hofmann - One of the best experts on this subject based on the ideXlab platform.
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A Miniaturized, Programmable Deep-Brain Stimulator for Group-Housing and Water Maze Use
Frontiers in Neuroscience, 2018Co-Authors: Richard C. Pinnell, Anne Pereira De Vasconcelos, Jean C Cassel, Ulrich G. HofmannAbstract:Pre-clinical Deep-Brain stimulation (DBS) research has observed a growing interest in the use of portable stimulation devices that can be carried by animals. Not only can such devices overcome many issues inherent with a cable tether, such as twisting or snagging, they can also be utilized in a greater variety of arenas, including enclosed or large mazes. However, these devices are not inherently designed for water-maze environments, and their use has been restricted to individually-housed rats in order to avoid damage from various social activities such as grooming, playing, or fighting. By taking advantage of 3D-printing techniques, this study demonstrates an ultra-small portable Stimulator with an environmentally-protective device housing, that is suitable for both social-housing and water-maze environments. The miniature device offers 2 channels of charge-balanced biphasic pulses with a high compliance voltage (12 V), a magnetic switch, and a diverse range of programmable stimulus parameters and pulse modes. The device's capabilities have been verified in both chronic pair-housing and water-maze experiments that asses the effects of nucleus reuniens DBS. Theta-burst stimulation delivered during a reference-memory water-maze task (but not before) had induced performance deficits during both the acquisition and probe trials of a reference memory task. The results highlight a successful application of 3D-printing for expanding on the range of measurement modalities capable in DBS research.
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Portable Stimulator for Group Housing and Water-Maze Use
2018Co-Authors: Richard Pinnell, Ulrich G. HofmannAbstract:This file set contains the design files and instructions for building a miniature portable Deep-Brain Stimulator for animal use. This device combines a miniature PCB assembly with 3D-printing, and can be utilised in both group-housing and water-maze environments.
Alastair J. Martin - One of the best experts on this subject based on the ideXlab platform.
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hemorrhage detection and incidence during magnetic resonance guided Deep Brain Stimulator implantations
Stereotactic and Functional Neurosurgery, 2017Co-Authors: Alastair J. Martin, Philip A Starr, Jill L Ostrem, Paul S. LarsonAbstract:Background/aims Intraoperative magnetic resonance imaging (iMRI) is increasingly used to implant Deep Brain Stimulator (DBS) electrodes. The approach has the advantages of a high targeting accuracy, minimization of Brain penetrations, and allowance of implantation under general anesthesia. The hemorrhagic complications of iMRI-guided DBS implantation have not been studied in a large series. We report on the incidence and characteristics of hemorrhage during these procedures. Methods Hemorrhage incidence was assessed in a series of 231 iMRI procedures (374 electrodes implanted). All patients had movement disorders and the subthalamic nucleus or the globus pallidus internus was typically targeted. Hemorrhage was detected with intra- or postoperative MRI or postoperative computed tomography. Hemorrhage was classified based on its point of origin and clinical impact. Results Hemorrhage and symptomatic hemorrhage were detected during 2.4 and 1.1% of electrode implantations, respectively. The hemorrhage origin was subdural/subarachnoid (n = 3), subcortical (n = 5), or Deep (n = 1). Factors that contributed to hemorrhage included unintentional crossing of a sulcus and resistance at the pial membrane, which produced cortical depression and a rebound hemorrhage. Delayed hemorrhage occurred in 2 patients and was attributed to premature reintroduction of anticoagulation therapy or air intrusion into the cranial cavity. Conclusions Hemorrhage was readily apparent on intraoperative imaging, and hemorrhage rates for iMRI-guided DBS implantations were comparable to those for conventional implantation approaches.
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Implantation of Deep Brain Stimulator Electrodes Using Interventional MRI
Neurosurgery clinics of North America, 2009Co-Authors: Philip A Starr, Alastair J. Martin, Paul S. LarsonAbstract:The authors describe a method for placement of Deep Brain Stimulator electrodes using interventional MRI in conjunction with a skull-mounted aiming device (Medtronic Nexframe). This approach adapts the procedure to a standard-configuration 1.5-T diagnostic MRI scanner in a radiology suite. Preoperative imaging, device implantation, and postimplantation MRI are integrated into a single procedure performed under general anesthesia, providing real-time, high-resolution magnetic resonance confirmation of electrode position. The method is conceptually simpler than the current standard technique for Deep Brain Stimulator placement, as it eliminates the stereotactic frame, the subsequent requirement for registration of the Brain in stereotactic space, physiologic testing, and the need for patient cooperation. With further technical refinement, the interventional MRI method should improve the accuracy, safety, and speed of Deep Brain Stimulator electrode placement.
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interventional magnetic resonance guidance of Deep Brain Stimulator implantation for parkinson disease
Topics in Magnetic Resonance Imaging, 2008Co-Authors: Alastair J. Martin, Jill L Ostrem, Paul S. Larson, Philip A StarrAbstract:Deep Brain stimulation is increasingly being applied to movement disorders, and other novel applications are emerging. The therapy requires precise localization of the stimulation electrode at specific target sites in Deep Brain structures. Conventional means of implantation rely on stereotactic approaches, which lack sufficient targeting accuracy and therefore are supported by invasive physiological mapping. We review the use of interventional magnetic resonance image guidance for the implantation of Deep Brain Stimulator electrodes in patients with moderate to advanced Parkinson disease. The methodologies used in this innovative surgical technique are presented, along with the potential benefits and limitations of such an approach. Targeting accuracies are shown to be within approximately 1 mm of the intended Deep Brain structure and are achieved with a single Brain penetration in most cases. Preliminary evaluation of clinical outcomes indicates comparable results to that achieved with conventional implantation methods, and the technique holds promise for substantially reducing operative durations.
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placement of Deep Brain Stimulator electrodes using real time high field interventional magnetic resonance imaging
Magnetic Resonance in Medicine, 2005Co-Authors: Jill L Ostrem, Alastair J. Martin, Paul S. Larson, Keith W Sootsman, Pekka Talke, Oliver M Weber, Nadja Levesque, Jeffrey N Myers, Philip A StarrAbstract:A methodology is presented for placing Deep Brain Stimulator electrodes under direct MR image guidance. The technique utilized a small, skull-mounted trajectory guide that is optimized for accurate alignment under MR fluoroscopy. Iterative confirmation scans are used to monitor device alignment and Brain penetration. The methodology was initially tested in a human skull phantom and proved capable of achieving submillimeter accuracy over a set of 16 separate targets that were accessed. The maximum error that was obtained in this preliminary test was 2 mm, motivating use of the technique in a clinical study. Subsequently, a total of eight Deep Brain stimulation electrodes were placed in five patients. Satisfactory placement was achieved on the first pass in seven of eight electrodes, while two passes were required with one electrode. Mean error from the intended target on the first pass was 1.0 +/- 0.8 mm (range = 0.1-1.9 mm). All procedures were considered technical successes and there were no intraoperative complications; however, one patient did develop a postoperative infection.
