深部脑刺激

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喵喵子（讨论 | 贡献）2022年7月7日 (四) 14:36的版本
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模板:Infobox medical intervention

Deep brain stimulation (DBS) is a neurosurgical procedure involving the placement of a medical device called a neurostimulator, which sends electrical impulses, through implanted electrodes, to specific targets in the brain (the brain nucleus) for the treatment of movement disorders, including Parkinson's disease, essential tremor, dystonia,[1] and other conditions such as obsessive-compulsive disorder (OCD) and epilepsy. While its underlying principles and mechanisms are not fully understood, DBS directly changes brain activity in a controlled manner.[2][3]

Deep brain stimulation (DBS) is a neurosurgical procedure involving the placement of a medical device called a neurostimulator, which sends electrical impulses, through implanted electrodes, to specific targets in the brain (the brain nucleus) for the treatment of movement disorders, including Parkinson's disease, essential tremor, dystonia, and other conditions such as obsessive-compulsive disorder (OCD) and epilepsy. While its underlying principles and mechanisms are not fully understood, DBS directly changes brain activity in a controlled manner.

脑深部电刺激(DBS)是神经外科手术（neurosurgical)中的操作之一，包括放置一种叫做神经刺激器( neurostimulator)的医疗设备，通过植入的电极(electrode)将电脉冲发送到大脑(brain)中的特定目标(脑核(brain nucleus)) ，治疗包括帕金森病(Parkinson's disease)、原发性震颤(essential tremor)、肌张力障碍(dystonia)[1]和其他疾病，如强迫症(obsessive-compulsive disorder)和癫痫(epilepsy)，引起的运动障碍。虽然其基本原理和机制尚不完全清楚，DBS 是一种可控的直接改变大脑活动的方式.[2][3]。

DBS has been approved by the Food and Drug Administration as a treatment for essential tremor and Parkinson's disease (PD) since 1997.[4] DBS was approved for dystonia in 2003,[5] Obsessive–compulsive disorder (OCD) in 2009, and epilepsy in 2018.[6][7][8] DBS has been studied in clinical trials as a potential treatment for chronic pain for various affective disorders, including major depression. It is one of few neurosurgical procedures that allow blinded studies.[1]

DBS has been approved by the Food and Drug Administration as a treatment for essential tremor and Parkinson's disease (PD) since 1997. DBS was approved for dystonia in 2003,'Brain pacemaker' treats dystonia. KNBC TV, April 22, 2003. Retrieved October 18, 2006. Obsessive–compulsive disorder (OCD) in 2009, and epilepsy in 2018. DBS has been studied in clinical trials as a potential treatment for chronic pain for various affective disorders, including major depression. It is one of few neurosurgical procedures that allow blinded studies.

1997年，DBS 已经被美国食品和药物管理局(Food and Drug Administration)批准用于治疗原发性震颤和帕金森病(Parkinson's disease)[4]。2003年被批准,以“脑起搏器”的方法用于肌张力障碍(dystonia)[5] ，2009年被批准用于强迫症，2018年用于癫痫[6][7][8]。DBS 已经在临床试验中被研究用作各种情感障碍(包括重度抑郁症(major depression))的慢性疼痛(chronic pain)的潜在治疗方法。这是少数允许盲法研究( blinded studies)的神经外科手术之一[1]。

Medical use

Insertion of electrode during surgery using a stereotactic frame

Parkinson's disease

DBS is used to manage some of the symptoms of Parkinson's disease that cannot be adequately controlled with medications.[9][10] PD is treated by applying high-frequency (> 100 Hz) stimulation to three target structures namely to entrolateral thalamus, internal pallidum, and subthalamic nucleus (STN) to mimic the clinical effects of lesioning.[11] It is recommended for people who have PD with motor fluctuations and tremor inadequately controlled by medication, or to those who are intolerant to medication, as long as they do not have severe neuropsychiatric problems.[12] Four areas of the brain have been treated with neural stimulators in PD. These are the globus pallidus internus, thalamus, subthalamic nucleus and the pedunculopontine nucleus. However, most DBS surgeries in routine practice target either the globus pallidus internus, or the Subthalamic nucleus.

  • DBS of the globus pallidus internus reduces uncontrollable shaking movements called dyskinesias. This enables a patient to take adequate quantities of medications (especially levodopa), thus leading to better control of symptoms.
  • DBS of the subthalamic nucleus directly reduces symptoms of Parkinson's. This enables a decrease in the dose of anti-parkinsonian medications.
  • DBS of the PPN may help with freezing of gait, while DBS of the thalamus may help with tremor. These targets are not routinely utilized.

DBS is used to manage some of the symptoms of Parkinson's disease that cannot be adequately controlled with medications.U.S. Department of Health and Human Services. FDA approves implanted brain stimulator to control tremors. Retrieved February 10, 2015. PD is treated by applying high-frequency (> 100 Hz) stimulation to three target structures namely to entrolateral thalamus, internal pallidum, and subthalamic nucleus (STN) to mimic the clinical effects of lesioning.Koller, W. and Melamed, E., 2007. Parkinson's disease and related disorders. 1st ed. Edinburgh: Elsevier. It is recommended for people who have PD with motor fluctuations and tremor inadequately controlled by medication, or to those who are intolerant to medication, as long as they do not have severe neuropsychiatric problems. Four areas of the brain have been treated with neural stimulators in PD. These are the globus pallidus internus, thalamus, subthalamic nucleus and the pedunculopontine nucleus. However, most DBS surgeries in routine practice target either the globus pallidus internus, or the Subthalamic nucleus.

  • DBS of the globus pallidus internus reduces uncontrollable shaking movements called dyskinesias. This enables a patient to take adequate quantities of medications (especially levodopa), thus leading to better control of symptoms.
  • DBS of the subthalamic nucleus directly reduces symptoms of Parkinson's. This enables a decrease in the dose of anti-parkinsonian medications.
  • DBS of the PPN may help with freezing of gait, while DBS of the thalamus may help with tremor. These targets are not routinely utilized.

DBS用于治疗帕金森病的一些无法用药完全控制的症状.[9][10] 。通过对丘脑内外侧、内苍白球和丘脑下核(STN)三个靶结构应用高频(> 100 Hz)刺激治疗PD，以模拟病变的临床效果[11] 。它适合推荐给药物控制不充分的运动波动和震颤的PD患者，或对药物不耐受的患者，只要他们没有严重的神经精神问题[12] 。在帕金森病中，有苍白球内（ globus pallidus internus）、丘脑（ thalamus）、丘脑下核（subthalamic nucleus）和桥脚核（pedunculopontine nucleus）四个脑区使用神经刺激器进行治疗。然而，在常规手术中，大多数DBS手术不是针对苍白球内，就是针对丘脑下核。

  • 苍白球内的DBS减少了不可控的震颤运动，称为运动障碍（dyskinesias）。这使患者能够服用足够数量的药物(特别是左旋多巴)，从而更好地控制症状。
  • 丘脑底核深部脑刺激可直接减轻帕金森病症状。这可以减少抗帕金森药物的剂量。
  • PPN的DBS可能有助于步态冻结，而丘脑的DBS可能有助于颤抖。这些靶标通常不被使用。

Selection of the correct DBS target is a complicated process. Multiple clinical characteristics are used to select the target including – identifying the most troublesome symptoms, the dose of levodopa that the patient is currently taking, the effects and side-effects of current medications and concurrent problems. For example, subthalamic nucleus DBS may worsen depression and hence is not preferred in patients with uncontrolled depression.

Selection of the correct DBS target is a complicated process. Multiple clinical characteristics are used to select the target including – identifying the most troublesome symptoms, the dose of levodopa that the patient is currently taking, the effects and side-effects of current medications and concurrent problems. For example, subthalamic nucleus DBS may worsen depression and hence is not preferred in patients with uncontrolled depression.

选择正确的 DBS 目标是一个复杂的过程。多种临床特征被用来选择目标，包括识别最棘手的症状、患者目前正在服用的左旋多巴的剂量、当前药物的作用和副作用以及同时出现的问题。例如，丘脑下核 DBS 可能会加重抑郁症，因此对于无法控制的抑郁症患者来说并不是首选。

Generally DBS is associated with 30–60% improvement in motor score evaluations.[13]

Generally DBS is associated with 30–60% improvement in motor score evaluations.

一般来说，DBS 与运动成绩评定的30-60% 的改善有关[13]。

Tourette syndrome

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DBS has been used experimentally in treating adults with severe Tourette syndrome who do not respond to conventional treatment. Despite widely publicized early successes, DBS remains a highly experimental procedure for the treatment of Tourette's, and more study is needed to determine whether long-term benefits outweigh the risks.[14][15][16][17] The procedure is well tolerated, but complications include "short battery life, abrupt symptom worsening upon cessation of stimulation, hypomanic or manic conversion, and the significant time and effort involved in optimizing stimulation parameters".[18] As of 2006, five people with TS had been reported on; all experienced reduction in tics and the disappearance of obsessive-compulsive behaviors.[18]

DBS has been used experimentally in treating adults with severe Tourette syndrome who do not respond to conventional treatment. Despite widely publicized early successes, DBS remains a highly experimental procedure for the treatment of Tourette's, and more study is needed to determine whether long-term benefits outweigh the risks. Also see Tourette Syndrome Association. Statement: Deep Brain Stimulation and Tourette Syndrome. Retrieved November 22, 2005. The procedure is well tolerated, but complications include "short battery life, abrupt symptom worsening upon cessation of stimulation, hypomanic or manic conversion, and the significant time and effort involved in optimizing stimulation parameters". As of 2006, five people with TS had been reported on; all experienced reduction in tics and the disappearance of obsessive-compulsive behaviors.

DBS已被实验性地用于治疗对常规治疗没有反应的成人严重图雷特综合征（ Tourette syndrome）。尽管早期的成功被广泛宣传，DBS治疗图雷特氏症仍然是一个高度实验性（experimental ）的程序，需要更多的研究来确定长期的好处是否大于风险[14][15][16][17] 。该手术耐受性良好，但并发症包括“电池寿命短，停止刺激后症状突然恶化，轻度躁狂或躁狂转化，以及优化刺激参数所需的大量时间和精力”[18] 。截至2006年，有5人被报告患有TS;所有人都经历了抽搐的减少和强迫行为的消失[18]。

The procedure is invasive and expensive, and requires long-term expert care. Benefits for severe Tourette's are not conclusive, considering less robust effects of this surgery seen in the Netherlands. Tourette's is more common in pediatric populations, tending to remit in adulthood, so in general this would not be a recommended procedure for use on children. Because diagnosis of Tourette's is made based on a history of symptoms rather than analysis of neurological activity, it may not always be clear how to apply DBS for a particular person. Due to concern over the use of DBS in Tourette syndrome treatment, the Tourette Association of America convened a group of experts to develop recommendations guiding the use and potential clinical trials of DBS for TS.[19]

The procedure is invasive and expensive, and requires long-term expert care. Benefits for severe Tourette's are not conclusive, considering less robust effects of this surgery seen in the Netherlands. Tourette's is more common in pediatric populations, tending to remit in adulthood, so in general this would not be a recommended procedure for use on children. Because diagnosis of Tourette's is made based on a history of symptoms rather than analysis of neurological activity, it may not always be clear how to apply DBS for a particular person. Due to concern over the use of DBS in Tourette syndrome treatment, the Tourette Association of America convened a group of experts to develop recommendations guiding the use and potential clinical trials of DBS for TS.

这种手术具有侵入性，费用昂贵，需要长期的专家护理。考虑到在荷兰（ Netherlands）进行的这种手术效果较差，重度抽动秽语综合症的益处还不能下结论。抽动秽语综合症在儿童群体中更为常见，成年后趋于缓解，所以一般不推荐在儿童身上使用这种疗法。因为抽动秽语综合症的诊断是基于症状的历史而不是神经活动的分析，所以如何为特定的人应用 DBS 并不总是很清楚。由于担心使用DBS治疗抽动秽语综合症（Tourette syndrome treatment），美国图雷特协会（ Tourette Association of America）召集了一组专家来制定建议，指导DBS治疗TS的使用和潜在的临床试验（clinical trials）[19]。

Robertson reported that DBS had been used on 55 adults by 2011, remained an experimental treatment at that time, and recommended that the procedure "should only be conducted by experienced functional neurosurgeons operating in centres which also have a dedicated Tourette syndrome clinic".[15] According to Malone et al. (2006), "Only patients with severe, debilitating, and treatment-refractory illness should be considered; while those with severe personality disorders and substance-abuse problems should be excluded."[18] Du et al. (2010) say, "As an invasive therapy, DBS is currently only advisable for severely affected, treatment-refractory TS adults".[16] Singer (2011) says, "pending determination of patient selection criteria and the outcome of carefully controlled clinical trials, a cautious approach is recommended".[14] Viswanathan et al. (2012) say DBS should be used for people with "severe functional impairment that cannot be managed medically".[20]

Robertson reported that DBS had been used on 55 adults by 2011, remained an experimental treatment at that time, and recommended that the procedure "should only be conducted by experienced functional neurosurgeons operating in centres which also have a dedicated Tourette syndrome clinic". According to Malone et al. (2006), "Only patients with severe, debilitating, and treatment-refractory illness should be considered; while those with severe personality disorders and substance-abuse problems should be excluded." Du et al. (2010) say, "As an invasive therapy, DBS is currently only advisable for severely affected, treatment-refractory TS adults". Singer (2011) says, "pending determination of patient selection criteria and the outcome of carefully controlled clinical trials, a cautious approach is recommended". Viswanathan et al. (2012) say DBS should be used for people with "severe functional impairment that cannot be managed medically".

Robertson 报告说，截至2011年，DBS 已经在55名成年人身上使用，在当时仍然是一种试验性的治疗方法，并且建议这种手术“应该只由有经验的功能性神经外科医生进行，这些医生所在的中心还有一个专门的图雷特氏综合症诊所”[15] 。根据Malone等人的说法(2006年) ，“只有患有严重的、使人衰弱的和治疗难以治愈的疾病的患者才应该被考虑; 而那些有严重的人格障碍和物质滥用问题的患者应该被排除在外“"[18]。Du 等人(2010)说，“作为一种侵入性治疗，DBS 目前仅适用于严重受影响、治疗难治性 TS 的成年人”[16] 。Singer (2011年)说，“在确定患者选择标准和仔细控制的临床试验结果之前，建议采取谨慎的方法”[14]。Viswanathan等人(2012)表示，DBS 应该用于“严重功能障碍且无法医学治疗”的患者。

Adverse effects

Arteriogram of the arterial supply that can hemorrhage during DBS implantation.

thumb|left|Arteriogram of the arterial supply that can hemorrhage during DBS implantation.

拇指|左| DBS植入时可出血的动脉供应动脉造影。

DBS carries the risks of major surgery, with a complication rate related to the experience of the surgical team. The major complications include hemorrhage (1–2%) and infection (3–5%).[21]

DBS carries the risks of major surgery, with a complication rate related to the experience of the surgical team. The major complications include hemorrhage (1–2%) and infection (3–5%).

DBS具有大手术的风险，并发症的发生率与手术团队的经验有关。主要并发症包括出血(1-2%)和感染(3-5%)[21]。

The potential exists for neuropsychiatric side effects after DBS, including apathy, hallucinations, hypersexuality, cognitive dysfunction, depression, and euphoria. However, these effects may be temporary and related to (1) correct placement of electrodes, (2) open-loop VS closed loop stimulation , meaning a constant stimulation or an A.I. monitoring delivery system[22] and (3) calibration of the stimulator, so these side effects are potentially reversible.[23]

The potential exists for neuropsychiatric side effects after DBS, including apathy, hallucinations, hypersexuality, cognitive dysfunction, depression, and euphoria. However, these effects may be temporary and related to (1) correct placement of electrodes, (2) open-loop VS closed loop stimulation , meaning a constant stimulation or an A.I. monitoring delivery system and (3) calibration of the stimulator, so these side effects are potentially reversible.

DBS 有可能导致神经精神（neuropsychiatric）方面的副作用，包括冷漠（apathy）、幻觉（hallucinations）、性欲亢进（hypersexuality）、认知功能障碍（cognitive dysfunction）、抑郁（depression）和欣快感（euphoria）。然而，这些影响可能是暂时的，与(1)电极的正确放置，(2)开环VS闭环刺激，意味着持续刺激或人工智能监测传输系统[22] ，以及(3)刺激器的校准有关，因此这些副作用可能是可逆的[23]。

Because the brain can shift slightly during surgery, the electrodes can become displaced or dislodged from the specific location. This may cause more profound complications such as personality changes, but electrode misplacement is relatively easy to identify using CT scan. Also, complications of surgery may occur, such as bleeding within the brain. After surgery, swelling of the brain tissue, mild disorientation, and sleepiness are normal. After 2–4 weeks, a follow-up visit is used to remove sutures, turn on the neurostimulator, and program it.[citation needed]

Because the brain can shift slightly during surgery, the electrodes can become displaced or dislodged from the specific location. This may cause more profound complications such as personality changes, but electrode misplacement is relatively easy to identify using CT scan. Also, complications of surgery may occur, such as bleeding within the brain. After surgery, swelling of the brain tissue, mild disorientation, and sleepiness are normal. After 2–4 weeks, a follow-up visit is used to remove sutures, turn on the neurostimulator, and program it.

因为在手术过程中大脑可能会轻微移动，电极可能会从特定位置移位或移位。这可能会导致更深刻的并发症，如个性（personality ）的改变，但电极错位使用CT扫描（CT scan）相对容易识别。此外，手术并发症也可能发生，如脑出血。手术后，脑组织肿胀、轻度定向障碍和嗜睡均属正常。2-4周后，进行随访，拆除缝合线，打开神经刺激器，并对其进行编程。

Impaired swimming skills surfaced as an unexpected risk of the procedure; several Parkinson's disease patients lost their ability to swim after receiving deep brain stimulation.[24][25]

Impaired swimming skills surfaced as an unexpected risk of the procedure; several Parkinson's disease patients lost their ability to swim after receiving deep brain stimulation.

游泳技能受损被认为是该手术的一个意外风险;几名帕金森氏症患者在接受脑深部刺激后失去了游泳能力[24][25]。

Mechanisms

The exact mechanism of action of DBS is not known.[26] A variety of hypotheses try to explain the mechanisms of DBS:[27][28]

The exact mechanism of action of DBS is not known. A variety of hypotheses try to explain the mechanisms of DBS:

DBS 的确切作用机制尚不清楚。各种各样的假说试图解释 DBS 的机制:

  1. Depolarization blockade: Electrical currents block the neuronal output at or near the electrode site.
  2. Synaptic inhibition: This causes an indirect regulation of the neuronal output by activating axon terminals with synaptic connections to neurons near the stimulating electrode.
  3. Desynchronization of abnormal oscillatory activity of neurons
  4. Antidromic activation either activating/blockading distant neurons or blockading slow axons[3]
  1. Depolarization blockade: Electrical currents block the neuronal output at or near the electrode site.
  2. Synaptic inhibition: This causes an indirect regulation of the neuronal output by activating axon terminals with synaptic connections to neurons near the stimulating electrode.
  3. Desynchronization of abnormal oscillatory activity of neurons
  4. Antidromic activation either activating/blockading distant neurons or blockading slow axons
  1. 去极化阻滞: 电流阻断电极附近的神经元输出。
  2. 突触抑制: 通过激活与刺激电极附近的神经元有突触连接的轴突终末来间接调节神经元的输出。
  3. 神经元异常振荡活动的去同步化。
  4. 逆向激活或激活/阻塞远处的神经元或阻塞缓慢的轴突。

DBS represents an advance on previous treatments which involved pallidotomy (i.e., surgical ablation of the globus pallidus) or thalamotomy (i.e., surgical ablation of the thalamus).[29] Instead, a thin lead with multiple electrodes is implanted in the globus pallidus, nucleus ventralis intermedius thalami, or subthalamic nucleus, and electric pulses are used therapeutically. The lead from the implant is extended to the neurostimulator under the skin in the chest area.[citation needed]

DBS represents an advance on previous treatments which involved pallidotomy (i.e., surgical ablation of the globus pallidus) or thalamotomy (i.e., surgical ablation of the thalamus). Instead, a thin lead with multiple electrodes is implanted in the globus pallidus, nucleus ventralis intermedius thalami, or subthalamic nucleus, and electric pulses are used therapeutically. The lead from the implant is extended to the neurostimulator under the skin in the chest area.

DBS 代表了先前苍白球切开术(即手术切除苍白球)或丘脑切开术(即手术切除丘脑)治疗方法的进步。取而代之的是，在苍白球、中间丘脑腹侧核或丘脑下核内植入一个带有多个电极的薄导线，并用电脉冲进行治疗。植入物的导线延伸到胸部皮肤下的神经刺激器。

Its direct effect on the physiology of brain cells and neurotransmitters is currently debated, but by sending high-frequency electrical impulses into specific areas of the brain, it can mitigate symptoms[30] and directly diminish the side effects induced by PD medications,[31] allowing a decrease in medications, or making a medication regimen more tolerable.[citation needed]

Its direct effect on the physiology of brain cells and neurotransmitters is currently debated, but by sending high-frequency electrical impulses into specific areas of the brain, it can mitigate symptoms and directly diminish the side effects induced by PD medications, allowing a decrease in medications, or making a medication regimen more tolerable.

它对脑细胞和神经递质生理机能的直接影响目前还存在争议，但通过向大脑特定区域发送高频电脉冲，它可以缓解症状，直接减轻 PD 药物引起的副作用，减少药物治疗，或使药物治疗更能耐受。

Components and placement

The DBS system consists of three components: the implanted pulse generator (IPG), the lead, and an extension. The IPG is a battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain that interfere with neural activity at the target site. The lead is a coiled wire insulated in polyurethane with four platinum-iridium electrodes and is placed in one or two different nuclei of the brain. The lead is connected to the IPG by an extension, an insulated wire that runs below the skin, from the head, down the side of the neck, behind the ear, to the IPG, which is placed subcutaneously below the clavicle, or in some cases, the abdomen.[9] The IPG can be calibrated by a neurologist, nurse, or trained technician to optimize symptom suppression and control side effects.[32]

The DBS system consists of three components: the implanted pulse generator (IPG), the lead, and an extension. The IPG is a battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain that interfere with neural activity at the target site. The lead is a coiled wire insulated in polyurethane with four platinum-iridium electrodes and is placed in one or two different nuclei of the brain. The lead is connected to the IPG by an extension, an insulated wire that runs below the skin, from the head, down the side of the neck, behind the ear, to the IPG, which is placed subcutaneously below the clavicle, or in some cases, the abdomen.National Institute of Neurological Disorders and Stroke. Deep brain stimulation for Parkinson's disease information page Retrieved November 23, 2006. The IPG can be calibrated by a neurologist, nurse, or trained technician to optimize symptom suppression and control side effects.

= = 组件和放置 = = DBS 系统由三部分组成: 植入式脉冲发生器(IPG)、引线和扩展。IPG 是一种电池驱动的神经刺激器，安装在钛合金外壳内，向大脑发送电脉冲，干扰目标位置的神经活动。导线是一个由四个铂铱电极和聚氨酯绝缘的盘绕电线，被放置在大脑的一个或两个不同的细胞核中。导线通过延长连接到 IPG，这是一根绝缘导线，从皮肤下面，从头部，沿着脖子的一侧，在耳朵后面，连接到 IPG，这是放在锁骨下皮下，或在某些情况下，放在腹部。全国神经紊乱和中风研究院。脑深部电刺激治疗帕金森病信息检索页2006年11月23日。IPG 可以由神经科医生、护士或受过训练的技术人员进行校准，以优化症状抑制和控制副作用。

DBS leads are placed in the brain according to the type of symptoms to be addressed. For non-Parkinsonian essential tremor, the lead is placed in either the ventrointermediate nucleus of the thalamus or the zona incerta;[33] for dystonia and symptoms associated with PD (rigidity, bradykinesia/akinesia, and tremor), the lead may be placed in either the globus pallidus internus or the subthalamic nucleus; for OCD and depression to the nucleus accumbens; for incessant pain to the posterior thalamic region or periaqueductal gray; and for epilepsy treatment to the anterior thalamic nucleus.[34]

DBS leads are placed in the brain according to the type of symptoms to be addressed. For non-Parkinsonian essential tremor, the lead is placed in either the ventrointermediate nucleus of the thalamus or the zona incerta; for dystonia and symptoms associated with PD (rigidity, bradykinesia/akinesia, and tremor), the lead may be placed in either the globus pallidus internus or the subthalamic nucleus; for OCD and depression to the nucleus accumbens; for incessant pain to the posterior thalamic region or periaqueductal gray; and for epilepsy treatment to the anterior thalamic nucleus.Deep brain stimulation. Surgery Encyclopedia. Retrieved January 25, 2007.

根据需要处理的症状类型，DBS 导联被放置在大脑中。对于非帕金森病的原发性震颤，铅可以放在丘脑腹中间核或脑带; 对于肌张力障碍和与帕金森病(强直、运动迟缓/运动不能和震颤)相关的症状，铅可以放在丘脑下核内核或者脑伏隔核内核; 对于强迫症和抑郁症; 对于丘脑后部区域或中脑导水管周围灰质持续疼痛; 对于丘脑前部癫痫核治疗。脑深部刺激。外科百科全书。25,2007.

All three components are surgically implanted inside the body. Lead implantation may take place under local anesthesia or under general anesthesia ("asleep DBS") such as for dystonia. A hole about 14 mm in diameter is drilled in the skull and the probe electrode is inserted stereotactically, using either frame-based or frameless stereotaxis.[35] During the awake procedure with local anesthesia, feedback from the person is used to determine the optimal placement of the permanent electrode. During the asleep procedure, intraoperative MRI guidance is used for direct visualization of brain tissue and device.[36] The installation of the IPG and extension leads occurs under general anesthesia.[37] The right side of the brain is stimulated to address symptoms on the left side of the body and vice versa.[citation needed]

All three components are surgically implanted inside the body. Lead implantation may take place under local anesthesia or under general anesthesia ("asleep DBS") such as for dystonia. A hole about 14 mm in diameter is drilled in the skull and the probe electrode is inserted stereotactically, using either frame-based or frameless stereotaxis. During the awake procedure with local anesthesia, feedback from the person is used to determine the optimal placement of the permanent electrode. During the asleep procedure, intraoperative MRI guidance is used for direct visualization of brain tissue and device. The installation of the IPG and extension leads occurs under general anesthesia.Deep Brain Stimulation, Department of Neurological Surgery, University of Pittsburgh. Retrieved May 13, 2008. The right side of the brain is stimulated to address symptoms on the left side of the body and vice versa.

所有这三个组件都是通过手术植入体内的。植入铅可以在局部麻醉或全身麻醉(“睡眠 DBS”)下进行，如肌张力障碍。在颅骨上钻一个直径约14毫米的孔，并立体地插入探针电极，使用基于框架或无框架的立体定向。在局部麻醉下的清醒手术中，通过病人的反馈来确定永久电极的最佳位置。在睡眠过程中，术中 MRI 引导用于直接显示脑组织和设备。在全身麻醉下进行 IPG 和延长导联的安装。深部脑刺激，匹兹堡大学神经外科系。13,2008.大脑的右半球受到刺激来解决身体左半球的症状，反之亦然。

Research

Chronic pain

Stimulation of the periaqueductal gray and periventricular gray for nociceptive pain, and the internal capsule, ventral posterolateral nucleus, and ventral posteromedial nucleus for neuropathic pain has produced impressive results with some people, but results vary. One study[38] of 17 people with intractable cancer pain found that 13 were virtually pain free and only four required opioid analgesics on release from hospital after the intervention. Most ultimately did resort to opioids, usually in the last few weeks of life.[39] DBS has also been applied for phantom limb pain.[40]

Stimulation of the periaqueductal gray and periventricular gray for nociceptive pain, and the internal capsule, ventral posterolateral nucleus, and ventral posteromedial nucleus for neuropathic pain has produced impressive results with some people, but results vary. One study of 17 people with intractable cancer pain found that 13 were virtually pain free and only four required opioid analgesics on release from hospital after the intervention. Most ultimately did resort to opioids, usually in the last few weeks of life. DBS has also been applied for phantom limb pain.

慢性疼痛刺激中脑导水管周围灰质和脑室周围灰质以治疗伤害性疼痛，内囊、腹外侧核和神经性疼痛内侧中央核对于一些人已经产生了令人印象深刻的结果，但是结果不一。一项对17名顽固性癌症疼痛患者的研究发现，其中13人几乎没有疼痛，只有4人在干预后出院时需要服用阿片类镇痛药。大多数人最终依靠阿片类药物，通常是在生命的最后几周。DBS 也用于治疗幻肢痛。

Major depression and obsessive-compulsive disorder

Lateral X-ray of the head: Deep brain stimulation in Obsessive–compulsive disorder (OCD). 42 year old man, surgery in 2013.

DBS has been used in a small number of clinical trials to treat people with severe treatment-resistant depression (TRD).[41] A number of neuroanatomical targets have been used for DBS for TRD including the subgenual cingulate gyrus, posterior gyrus rectus,[42] nucleus accumbens,[43] ventral capsule/ventral striatum, inferior thalamic peduncle, and the lateral habenula.[41] A recently proposed target of DBS intervention in depression is the superolateral branch of the medial forebrain bundle; its stimulation lead to surprisingly rapid antidepressant effects.[44]

DBS has been used in a small number of clinical trials to treat people with severe treatment-resistant depression (TRD). A number of neuroanatomical targets have been used for DBS for TRD including the subgenual cingulate gyrus, posterior gyrus rectus, nucleus accumbens, ventral capsule/ventral striatum, inferior thalamic peduncle, and the lateral habenula. A recently proposed target of DBS intervention in depression is the superolateral branch of the medial forebrain bundle; its stimulation lead to surprisingly rapid antidepressant effects.

DBS 已经在少数临床试验中用于治疗严重难治性抑郁症(TRD)患者。目前已有多种神经解剖学靶点用于视网膜下区(DBS) TRD 的研究，包括扣带回下部、直回后部、伏隔核、腹侧囊/腹侧纹状体、丘脑下端和外侧缰核。最近提出的 DBS 干预抑郁症的目标是前脑内侧神经束的上外侧分支; 它的刺激导致了惊人的快速抗抑郁作用。

The small numbers in the early trials of DBS for TRD currently limit the selection of an optimal neuroanatomical target.[41] Evidence is insufficient to support DBS as a therapeutic modality for depression; however, the procedure may be an effective treatment modality in the future.[45] In fact, beneficial results have been documented in the neurosurgical literature, including a few instances in which people who were deeply depressed were provided with portable stimulators for self treatment.[46][47][48]

The small numbers in the early trials of DBS for TRD currently limit the selection of an optimal neuroanatomical target. Evidence is insufficient to support DBS as a therapeutic modality for depression; however, the procedure may be an effective treatment modality in the future. In fact, beneficial results have been documented in the neurosurgical literature, including a few instances in which people who were deeply depressed were provided with portable stimulators for self treatment.

DBS 治疗 TRD 的早期试验数量较少，目前限制了最佳神经解剖靶点的选择。证据不足以支持 DBS 作为抑郁症的治疗方式，但是，该程序可能是一个有效的治疗方式在未来。事实上，神经外科文献已经记录了有益的结果，包括一些深度抑郁患者获得便携式刺激器进行自我治疗的例子。

A systematic review of DBS for TRD and OCD identified 23 cases, nine for OCD, seven for TRD, and one for both. "[A]bout half the patients did show dramatic improvement" and adverse events were "generally trivial" given the younger age of the psychiatric population relative to the age of people with movement disorders.[49] The first randomized, controlled study of DBS for the treatment of TRD targeting the ventral capsule/ventral striatum area did not demonstrate a significant difference in response rates between the active and sham groups at the end of a 16-week study.[50] However, a second randomized controlled study of ventral capsule DBS for TRD did demonstrate a significant difference in response rates between active DBS (44% responders) and sham DBS (0% responders).[51] Efficacy of DBS is established for OCD, with on average 60% responders in severely ill and treatment-resistant patients.[52] Based on these results the Food and Drug Administration (FDA) has approved DBS for treatment-resistant OCD under a Humanitarian Device Exemption (HDE), requiring that the procedure be performed only in a hospital with specialist qualifications to do so.

A systematic review of DBS for TRD and OCD identified 23 cases, nine for OCD, seven for TRD, and one for both. "[A]bout half the patients did show dramatic improvement" and adverse events were "generally trivial" given the younger age of the psychiatric population relative to the age of people with movement disorders. The first randomized, controlled study of DBS for the treatment of TRD targeting the ventral capsule/ventral striatum area did not demonstrate a significant difference in response rates between the active and sham groups at the end of a 16-week study. However, a second randomized controlled study of ventral capsule DBS for TRD did demonstrate a significant difference in response rates between active DBS (44% responders) and sham DBS (0% responders). Efficacy of DBS is established for OCD, with on average 60% responders in severely ill and treatment-resistant patients. Based on these results the Food and Drug Administration (FDA) has approved DBS for treatment-resistant OCD under a Humanitarian Device Exemption (HDE), requiring that the procedure be performed only in a hospital with specialist qualifications to do so.

一项针对 TRD 和 OCD 的深部脑震荡系统综述确诊了23例，其中9例为强迫症，7例为 TRD，还有一例两者都有。“一半的病人确实显示出了显著的改善”，并且不良事件“通常是微不足道的”，因为相对于运动障碍患者的年龄来说，精神病患者的年龄更小。在一项为期16周的研究结束时，针对腹侧被膜/腹侧纹状体区域的 DBS 治疗 TRD 的首次随机对照研究并没有显示活跃组和假手术组的有效率有显著差异。然而，第二个随机对照研究腹腔胶囊 DBS 治疗 TRD 的结果显示，活动性 DBS (44% 有效者)和假 DBS (0% 有效者)的有效率有显著差异。DBS 对强迫症的疗效已经确立，在重症患者和难治性患者中平均有60% 的反应。基于这些结果，美国食品和药物管理局(FDA)根据人道主义器械豁免(HDE)批准 DBS 用于耐药性强迫症，要求只有在具有专家资格的医院才能进行这种手术。

DBS for TRD can be as effective as antidepressants and can have good response and remission rates, but adverse effects and safety must be more fully evaluated. Common side effects include "wound infection, perioperative headache, and worsening/irritable mood [and] increased suicidality".[53]

DBS for TRD can be as effective as antidepressants and can have good response and remission rates, but adverse effects and safety must be more fully evaluated. Common side effects include "wound infection, perioperative headache, and worsening/irritable mood [and] increased suicidality".

DBS 治疗 TRD 可以和抗抑郁药物一样有效，并且有良好的反应和缓解率，但是不良反应和安全性必须进行更充分的评估。常见的副作用包括“伤口感染、围手术期头痛、情绪恶化/易激情绪[和]自杀倾向增加”。

Other clinical applications

Results of DBS in people with dystonia, where positive effects often appear gradually over a period of weeks to months, indicate a role of functional reorganization in at least some cases.[54] The procedure has been tested for effectiveness in people with epilepsy that is resistant to medication.[55] DBS may reduce or eliminate epileptic seizures with programmed or responsive stimulation.[citation needed]

Results of DBS in people with dystonia, where positive effects often appear gradually over a period of weeks to months, indicate a role of functional reorganization in at least some cases. The procedure has been tested for effectiveness in people with epilepsy that is resistant to medication. DBS may reduce or eliminate epileptic seizures with programmed or responsive stimulation.

在肌张力障碍患者中 DBS 的其他临床应用结果，其积极作用通常在数周至数月内逐渐显现，至少在某些情况下表明了功能重组的作用。这种方法已经在对药物耐药的癫痫患者身上进行了有效性测试。DBS 可以通过程序性或反应性刺激减少或消除癫痫发作。

DBS of the septal areas of persons with schizophrenia have resulted in enhanced alertness, cooperation, and euphoria.[56] Persons with narcolepsy and complex-partial seizures also reported euphoria and sexual thoughts from self-elicited DBS of the septal nuclei.[47]

DBS of the septal areas of persons with schizophrenia have resulted in enhanced alertness, cooperation, and euphoria. Persons with narcolepsy and complex-partial seizures also reported euphoria and sexual thoughts from self-elicited DBS of the septal nuclei.

精神分裂症患者的房间隔区域的 DBS 导致了警觉性、合作性和欣快感的增强。嗜睡症和复杂部分癫痫患者也报告了自我诱发的隔核 DBS 所引起的欣快感和性想法。

Orgasmic ecstasy was reported with the electrical stimulation of the brain with depth electrodes in the left hippocampus at 3mA, and the right hippocampus at 1 mA.[57]

Orgasmic ecstasy was reported with the electrical stimulation of the brain with depth electrodes in the left hippocampus at 3mA, and the right hippocampus at 1 mA.

用深度电极电刺激大脑左侧海马3毫安，右侧海马1毫安。

In 2015, a group of Brazilian researchers led by neurosurgeon 模板:Ill described a new technique that allows for simultaneous implants of electrodes called bilateral stereotactic procedure for DBS. The main benefits are less time spent on the procedure and greater accuracy.[58]

In 2015, a group of Brazilian researchers led by neurosurgeon described a new technique that allows for simultaneous implants of electrodes called bilateral stereotactic procedure for DBS. The main benefits are less time spent on the procedure and greater accuracy.

2015年，由神经外科医生领导的一组巴西研究人员描述了一种新技术，该技术允许同时植入电极，称为 DBS 的双侧立体定向手术。主要的好处是花在手术上的时间更少，而且更准确。

In 2016, DBS was found to improve learning and memory in a mouse model of Rett syndrome.[59] More recent (2018) work showed, that forniceal DBS upregulates genes involved in synaptic function, cell survival, and neurogenesis,[60] making some first steps at explaining the restoration of hippocampal circuit function.

In 2016, DBS was found to improve learning and memory in a mouse model of Rett syndrome. More recent (2018) work showed, that forniceal DBS upregulates genes involved in synaptic function, cell survival, and neurogenesis, making some first steps at explaining the restoration of hippocampal circuit function.

2016年，在一个瑞特综合征小鼠模型中，发现 DBS 能改善学习和记忆。最近(2018年)的研究表明，私通 DBS 上调了与突触功能、细胞存活和神经发生有关的基因，为解释海马回路功能的恢复迈出了第一步。

See also

模板:Col div

  • Brain implant
  • Electroconvulsive therapy
  • Electroencephalography
  • Neuromodulation (medicine)
  • Neuroprosthetics
  • Organization for Human Brain Mapping
  • Responsive neurostimulation device
  • Robert G. Heath


  • 植入大脑
  • 电痉挛疗法
  • 脑电图
  • 神经调节(医学)
  • 神经修复
  • 人脑映射组织
  • 响应性神经刺激疗法设备
  • Robert g. Heath

References

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  2. ↑ 2.0 2.1 Hammond C, Ammari R, Bioulac B, Garcia L (November 2008). "Latest view on the mechanism of action of deep brain stimulation" (PDF). Movement Disorders. 23 (15): 2111–21. doi:10.1002/mds.22120. PMID 18785230. S2CID 14905206.
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  6. ↑ 6.0 6.1 "Medtronic Receives FDA Approval for Deep Brain Stimulation Therapy for Medically Refractory Epilepsy". newsroom.medtronic.com. Retrieved 2018-12-18.
  7. ↑ 7.0 7.1 "FDA Approves Humanitarian Device Exemption for Deep Brain Stimulator for Severe Obsessive-Compulsive Disorder". FDA.
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  14. ↑ 14.0 14.1 14.2 14.3 "Tourette syndrome and other tic disorders". Hyperkinetic Movement Disorders. 100. March 2005. pp. 641–57. doi:10.1016/B978-0-444-52014-2.00046-X. ISBN 9780444520142. PMID 21496613.  Also see Singer HS (March 2005). "Tourette's syndrome: from behaviour to biology". The Lancet. Neurology. 4 (3): 149–59. doi:10.1016/S1474-4422(05)01012-4. PMID 15721825. S2CID 20181150.
  15. ↑ 15.0 15.1 15.2 15.3 Robertson MM (February 2011). "Gilles de la Tourette syndrome: the complexities of phenotype and treatment". British Journal of Hospital Medicine. 72 (2): 100–07. doi:10.12968/hmed.2011.72.2.100. PMID 21378617.
  16. ↑ 16.0 16.1 16.2 16.3 Du JC, Chiu TF, Lee KM, Wu HL, Yang YC, Hsu SY, Sun CS, Hwang B, Leckman JF (October 2010). "Tourette syndrome in children: an updated review". Pediatrics and Neonatology. 51 (5): 255–64. doi:10.1016/S1875-9572(10)60050-2. PMID 20951354.
  17. ↑ 17.0 17.1 Tourette Syndrome Association. Statement: Deep Brain Stimulation and Tourette Syndrome. Retrieved November 22, 2005.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 Malone DA, Pandya MM (2006). "Behavioral neurosurgery". Advances in Neurology. 99: 241–47. PMID 16536372.
  19. ↑ 19.0 19.1 Mink JW, Walkup J, Frey KA, Como P, Cath D, Delong MR, Erenberg G, Jankovic J, Juncos J, Leckman JF, Swerdlow N, Visser-Vandewalle V, Vitek JL (November 2006). "Patient selection and assessment recommendations for deep brain stimulation in Tourette syndrome" (PDF). Movement Disorders. 21 (11): 1831–38. doi:10.1002/mds.21039. hdl:2027.42/55891. PMID 16991144. S2CID 16353255.
  20. ↑ Viswanathan A, Jimenez-Shahed J, Baizabal Carvallo JF, Jankovic J (2012). "Deep brain stimulation for Tourette syndrome: target selection". Stereotactic and Functional Neurosurgery. 90 (4): 213–24. doi:10.1159/000337776. PMID 22699684.
  21. ↑ 21.0 21.1 Doshi PK (April 2011). "Long-term surgical and hardware-related complications of deep brain stimulation". Stereotactic and Functional Neurosurgery. 89 (2): 89–95. doi:10.1159/000323372. PMID 21293168. S2CID 10553177.
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  25. ↑ 25.0 25.1 Bangash, Omar K.; Thorburn, Megan; Garcia-Vega, Jimena; Walters, Susan; Stell, Rick; Starkstein, Sergio E.; Lind, Christopher R. P. (May 2016). "Drowning hazard with deep brain stimulation: case report". Journal of Neurosurgery. 124 (5): 1513–16. doi:10.3171/2015.5.JNS15589. ISSN 1933-0693. PMID 26566200.
  26. ↑ Mogilner A.Y.; Benabid A.L.; Rezai A.R. (2004). "Chronic Therapeutic Brain Stimulation: History, Current Clinical Indications, and Future Prospects". Bioelectromagnetic medicine. New York: Marcel Dekker. pp. 133–51. ISBN 978-0-8247-4700-8. 
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  36. ↑ Starr PA, Martin AJ, Ostrem JL, Talke P, Levesque N, Larson PS (March 2010). "Subthalamic nucleus deep brain stimulator placement using high-field interventional magnetic resonance imaging and a skull-mounted aiming device: technique and application accuracy". Journal of Neurosurgery. 112 (3): 479–90. doi:10.3171/2009.6.JNS081161. PMC 2866526. PMID 19681683.
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  38. ↑ Young RF & Brechner T (1986). "Electrical stimulation of the brain for relief of intractable pain due to cancer". Cancer. 57 (6): 1266–72. doi:10.1002/1097-0142(19860315)57:6<1266::aid-cncr2820570634>3.0.co;2-q. PMID 3484665.{{cite journal}}: CS1 maint: uses authors parameter (link)
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  41. ↑ 41.0 41.1 41.2 Anderson RJ, Frye MA, Abulseoud OA, Lee KH, McGillivray JA, Berk M, Tye SJ (September 2012). "Deep brain stimulation for treatment-resistant depression: efficacy, safety and mechanisms of action". Neuroscience and Biobehavioral Reviews. 36 (8): 1920–33. doi:10.1016/j.neubiorev.2012.06.001. PMID 22721950. S2CID 207089716.
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  43. ↑ Schlaepfer TE, Cohen MX, Frick C, Kosel M, Brodesser D, Axmacher N, Joe AY, Kreft M, Lenartz D, Sturm V (January 2008). "Deep brain stimulation to reward circuitry alleviates anhedonia in refractory major depression". Neuropsychopharmacology. 33 (2): 368–77. doi:10.1038/sj.npp.1301408. PMID 17429407.
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  45. ↑ Murphy, Destiny N.; Boggio, Paulo; Fregni, Felipe (2009). "Transcranial direct current stimulation as a therapeutic tool for the treatment of major depression: insights from past and recent clinical studies". Curr Opin Psychiatry. 22 (3): 306–11. doi:10.1097/YCO.0b013e32832a133f. PMID 19339889. S2CID 11392351.
  46. ↑ Delgado, Jose (1986). Physical Control of the Mind: Toward a Psychocivilized Society. New York: Harper and Row. ISBN 0-06-131914-7. 
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  60. ↑ Pohodich AE, Yalamanchili H, Raman AT, Wan YW, Gundry M, Hao S, Jin H, Tang J, Liu Z, Zoghbi HY (March 2018). "Forniceal deep brain stimulation induces gene expression and splicing changes that promote neurogenesis and plasticity". eLife. 7. doi:10.7554/elife.34031. PMC 5906096. PMID 29570050.

Further reading

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External links

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  • Video: Deep brain stimulation to treat Parkinson's disease
  • Video: Deep brain stimulation therapy for Parkinson's disease
  • The Perils of Deep Brain Stimulation for Depression. Author Danielle Egan. September 24, 2015.
  • Treatment center for Deep Brain Stimulation of movement disorders, OCD, Tourette or depression.
  • Treatment center for Deep Brain Stimulation for OCD


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类别: 电子疗法类别: 医疗设备类别: 神经内科手术类别: 神经修复类别: 神经外科手术类别: 神经技术类别: 神经图雷特氏综合症类别: 1987年引言


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