Objective: To retrospectively assess the use of directional programming in deep brain stimulation of globus pallidus pars interna (GPi-DBS) in patients with Parkinson’s disease (PD).

Background: The subthalamic nucleus (STN) and GPi have been shown to be effective DBS targets in advanced PD. GPi is preferred in patients with risk of cognitive decline. While experience with directionality in STN and the thalamus has been reported [1-6], the same in GPi is limited [7].

Method: We performed a retrospective chart review of programming parameters in 10 bilateral GPi-DBS patients (20 leads). All patients first underwent a monopolar review of the 4 omnidirectional montages on each lead 4 weeks after surgery. Directional programming was only evaluated in subsequent sessions when there was potential for further improvement in symptom relief. Programs were recorded only after stable settings were achieved. Total electrical energy delivered (TEED) and longevity estimates for the implanted primary cell pulse generators (IPG) were also calculated.

Results: Of ten patients (3 female) with a mean follow-up of 8.4 months, 6 were maintained on directional (9/20 leads). TEED and IPG longevity could be calculated for 8 patients. There was no statistical difference between TEED for the directional and omnidirectional settings. Mean IPG longevity was 4.4 years (3.25-6.25 years) based on the manufacturer’s calculator. Stable settings were achieved between 2-3 months. Single segment activation was used in 6 leads. Interestingly, 3 leads were programmed with vertically stacked directional activation, of which 2 of them were stacked single segments.

Conclusion: Here, we report the largest series of GPi-DBS using directional leads. Results from our initial experience suggest that directionality in GPi has clinical value not only for side effect avoidance but also when improvement in symptom relief is needed. Directional montages allow for current steering without the need for complex programming paradigms like bipolar or current fractionalization. Comparison of TEED suggests there is no difference in energy consumption between directional and omnidirectional GPi stimulation. This is also the first study to report longevity estimates for primary cell IPGs and directional leads in GPi-DBS.

References: 1. Rebelo P, Green AL, Aziz TZ, et al. Thalamic Directional Deep Brain Stimulation for tremor: Spend less, get more. Brain Stimul. 2018;11(3):600–606. doi:10.1016/j.brs.2017.12.015 2. Pollo C, Kaelin-Lang A, Oertel MF, et al. Directional deep brain stimulation: an intraoperative double-blind pilot study. Brain. 2014;137(Pt 7):2015–2026. doi:10.1093/brain/awu102 3. Contarino MF, Bour LJ, Verhagen R, et al. Directional steering: A novel approach to deep brain stimulation. Neurology. 2014;83(13):1163–1169. doi:10.1212/WNL.0000000000000823 4. Steigerwald F, Müller 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):1240–1243. doi:10.1002/mds.26669 5. 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):1380–1388. doi:10.1002/mds.27093 6. Schnitzler AS, Mir PM, Brodsky MB, et al. Directional versus omnidirectional Deep Brain Stimulation for Parkinson’s disease: Results of a prospective, blinded, multi center, single-arm crossover study. Mov Disord. 2019;34(suppl 2). 7. Anjum M, Fayed I, Torres-Yaghi Y, Pallavaram S, Kalhorn C, Amjad F, Zhang S, Pagan F, Vertically-stacked single segment activation (V-SSA) as a programming approach for Directional DBS in GPi: First Clinical case series. Mov Disord. Pan American Society 2020.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/uptake-in-directional-stimulation-and-primary-cell-longevity-in-deep-brain-stimulation-of-globus-pallidus-pars-interna-for-parkinsons-disease/