Objective: To evaluate in which patients, selected to receive a directional Deep Brain Stimulation (DBS) system, the advanced stimulation features were actually used.

Background: New DBS systems, including lead configuration with split electrodes in the middle positions, allow for directional stimulation and shorter pulse width. These advanced features can increase the threshold for side effects, thus enlarging the therapeutic window [1,2]. However, these systems are more expensive and limitedly available. Currently, there are no criteria to predict which patients would potentially benefit from advanced stimulation features and for which patients these would be unnecessary.

Method: We included all patients with Parkinson’s disease (PD), tremor or dystonia who underwent DBS with directional systems (2016-2020) in the Haga/LUMC DBS center, and had a minimum of 6-month follow-up.
The targets were: the subthalamic nucleus (STN), the ventral intermediate nucleus of the thalamus (Vim), or the internal globus pallidus (GPi). Surgery was performed as previously described [3].
Patients were selected to receive directional systems:
1) When the target was thalamus. 
2) When due to atrophy or blood vessels along the trajectory it was not possible to use microelectrorecordings.
3) When a small intraoperative therapeutic window was obtained on the first hemisphere.
All data were retrospectively collected from patients’ files.

Results: Forty-nine patients with bilateral leads and 2 patients with a single lead were included, comprising a total of 100 leads. At last follow-up, 28 patients (54.9%) were using the advanced features in one or both leads (40 leads in total, 40%), meaning these leads were programmed either for directional stimulation (n=9, 9%), a shorter pulse width (n=18, 18%) or both (n=13, 13%). Eleven out of 12 patients (92%) with leads in Vim were using the advanced features in one or both leads. For STN and GPi the proportion was 44% and 40% respectively. Furthermore, 100% of tremor patients (all implanted in Vim), 50% of PD patients, and 29% of dystonia patients were using the advanced features in one or both of the leads.

Conclusion: In our cohort all tremor patients and almost all leads implanted in the Vim area benefitted from the advanced features, suggesting that the choice of directional leads is warranted for this specific population.

References: [1] Steigerwald F, Muller L, Johannes S, Matthies C, Volkmann J. Directional deep brain stimulation of the subthalamic nucleus: A pilot study using a novel neurostimulation device. Mov Disord 2016; 31(8): 1240-3. [2] Dembek TA, Reker P, Visser-Vandewalle V, et al. Directional DBS increases side-effect thresholds-A prospective, double-blind trial. Mov Disord 2017; 32(10): 1380-8. [3] Geraedts VJ, van Ham RAP, Marinus J, et al. Intraoperative test stimulation of the subthalamic nucleus aids postoperative programming of chronic stimulation settings in Parkinson’s disease. Parkinsonism Relat Disord 2019; 65: 62-6.

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