DEEP BRAIN STIMULATION

AND VAGAL NERVE

STIMULATION
PRESENTED BY CRMI V.MONESHA
SYNOPSIS
 DEEP BRAIN STIMULATION
1. MECHANISM
2. INDICATIONS
3. DISADVANTAGES
 VAGAL NERVE STIMULATION
1. MECHANISM
2. INDICATIONS
3. DISADVANTAGES
 DEEP BRAIN STIMULATION?
 Introduced in the 1990s ,it is a neurosurgical procedure
involving the implantation of a medical device called
neurostimulator.
 It is the delivery of current to a specific subcortical grey matter
target to stimulate a desired group of nerve cells which results
in specific modulation the output of the involved neurocircuit.
 Deep brain stimulation (DBS) is an invasive neurosurgical
intervention being investigated for several psychiatric
disorders, most notably treatment-resistant depression (TRD)
and treatment-refractory obsessive-compulsive disorder
(OCD), but also Tourette’s Syndrome (TS), Alzheimer’s
dementia (AD), and addiction. 
 PRINCIPLES OF DBS?
 DBS is essentially an extracellular stimulation.
 Cathodal stimulation results in depolarization,if
superthreshold can evoke an action potential.
 Anodal stimulation causes hyperpolarization and
depolarization of nearby areas can also evoke action
potential.
 Stimulation can be monophasic,biphasic or polyphasic.
 Electrodes may be monopolar or bipolar.
 Stimulatory paramaters are
Amplitude(vol/milliamp) ,Frequency (duration of
pulse)and Pulse width(rate of pulse delivered).
 MECHANISM OF DBS
 Mechanism of DBS involves decoupling of
axonal and neuronal transport in basal ganglia
that takes place in corticospinopallidothalamic
tract.
 DBS is achieved by implanting one or more

electrode arrays (leads) into a specific region of

the brain via burr holes in the skull using
neuroimaging-guided stereotactic neurosurgical
techniques.Each array generally contains
several (typically four) electrode contacts
spanning 10–20 mm. DBS leads are connected
via subcutaneous extension wires to one or more
subcutaneously implanted pulse generators
(IPGs) containing the system battery and the
computer that drives stimulation; therefore, the
system is completely internalized within the
patient’s body.
 COMPONENTS OF DBS
 THE LEAD OR ELECTRODE: A
thin,insulated wire is inserted through a
small opening in the skill and implanted in
the brain.The tip of the electrode is
positioned within the targeted brain area.
 THE EXTENSION is an insulation wire
that is passed under the skin of head,neck
and shoulder, connecting the lead to the
neurostimulator.
 THE NEUROSTIMULATOR is the third
component that is usually implanted in the
skin under the collarbone.
INDICATIONS OF DBS

DISEASES SITE OF DBS ELECTRODE

 1.PARKINSON’S DISEASE  1.SUBTHALAMIC

NUCLEUS,GLOBUS PALLIDUS
 2.ESSENTIAL TREMOR  2.THALAMUS
 3.DYSTONIA  3.GLOBUS PALLIDUS
 4.EPILEPSY  4.HIPPOCAMPUS,THALAMUS
 5.TOURETT’S  5.GLOBUS PALLIDUS
SYNDROME INTERNUS,INTERNAL
CAPSULE
 6.OCD  6.VENTRAL
 7.THALAMIC PAIN HORN,SUBTHALAMIC
NUCLEUS,THALAMIC
PEDUNCLE
 7.VPL/VPM OF
THALAMUS,PVG/PAG OF
 DBS IN OCD
 OCD is defined by the presence of one or more markedly
distressing or functionally impairing obsessions (intrusive,
ruminative thoughts, images, or impulses) and/or compulsions
(highly repetitive mental or physical acts such as hand
washing, checking locks, counting, etc.
  Up to 60% of patients do not respond adequately to available
treatments,making treatment-refractory OCD a serious public
health problem.
 Stimulus is over ventral horn,inferior thalamic peduncle and
subthalamic nucleus.
 Most patients with refractory OCD showed no cognitive
changes with chronic stimulation, although some showed
improvements and others showed decrements.  A number of
case reports/series followed that suggested beneficial effects of
DBS of the ventral capsule (VC) and/or ventral striatum (VS)
in treatment-refractory OCD.
PATIENT SELECTION FOR DBS WITH PD

 Patient having PD
symptoms for 5 years.
 On/off fluctuations
within or without
dyskinesia.
 If PD symptoms
interfere with daily
activities.
 Continue to have a good
response to PD
medications especially
carbidopa or levodopa.
TECHNIQUE OF DBS
 The procedure is only used for patients whose
symptoms cannot be controlled with medication.
 Surgical implantation
 Targeted area is located by CT or MRI imaging.
 Quadripolar leads are connected to stimulator
and to battery.
 From stimulator,impulses are continously
delivered over wire to electrode in brain.
 Reprogramming can be done with 3,4 months.
 SIDE EFFECTS AND RISKS OF DBS
SIDE EFFECTS RISKS

 Headache,nausea,vomitting  Lead erosion

 Pain,swelling and  Lead malfunction
inflammation at the surgical  Malfunctioning of
site neurostimulator
 Confusion,numbness and  Seizures
weakness of the body  Dystonias
 Difficulty in speech  Hemorrhage
 Mood changes
 Bleeding in brain
 Movement disorders in brain
ADVANTAGES OF DBS IN PD
 DBS is not a cure for PD.
 It is a symptomatic therapy that helps relieve
motor as well as non motor symptoms of PD.
 Decreases Medications
 Improves tremors, rigidity, bradykinesia,
dyskinesia, gait problems in Thalamus,Globus
Pallidus and Subthalamic nucleus.
ADVANTAGES AND DISADVANTAGES OF DBS

ADVANTAGES DISADVANTAGES

 Reversibilty  Highly expensive

 Adjustibilty  Increased risk of
 Improves quality of life infection due to
 Helps to reduce implantation of
medications foreign object
 Relatively safe
procedure
 Improves energy level
 VAGAL NERVE STIMULATION
 Vagus nerve stimulation (VNS) is a 
medical treatment that involves delivering electrical
impulses to the vagus nerve. It is used as an add-on
treatment for certain types of intractable epilepsy
 and treatment-resistant depression.
 Afferents from the vagus nerve project to the 
nucleus tractus solitarii which communicates with
other regions of the brain including the 
dorsal raphe nucleus, locus coeruleus, amygdala and
other areas.
 VNS can change the activity of several 
neurotransmitter systems involving serotonin, 
norepinephrine and GABA.These neurotransmitters
are involved in both epilepsy and other
neuropsychiatric conditions such as depression and
anxiety.
 VNS IN PSYCHIATRY
 VNS is an implanted device with efficacy in pharmaco-resistant
epilepsy. It is also approved by the FDA for the treatment of
severe, recurrent unipolar and bipolar depression.
 As a therapeutic approach to affective disorders,
neuromodulation shifts the focus from the monoamine synapse
to neural circuitry of the brain, which is dysregulated in
depression.
 Invasive and non-invasive vagus nerve stimulation (VNS) is a
treatment for treatment-refractory depression, but is also
increasingly evaluated for its application in other psychiatric
disorders, such as dementia, schizophrenia, somatoform
disorder, and others.
VNS IN DEPRESSION
 VNS works by modulating the neural circuitry of
depression by stimulating vagal afferent fibers in the
neck, which carry impulses to the brain stem to target
there the locus ceruleus and dorsal raphe nucleus .
 Both devices, ECT and VNS, in turn are
complementary to pharmacotherapy and
psychotherapy of depression, and provide additional
options for the large number of patients who,
unfortunately, often fail to benefit from these first line
approaches.
 COMPONENTS OF VNS
 Programmable pulse
generator
 Bipolar lead
 Programming wand
with accompanying
software
 Tunnelling tool
 Hand held magnets
INDICATIONS OF VNS
NON EPILEPTIC
EPILEPTIC INDICATIONS
INDICATIONS
 CPS  ALZHEIMERS DISEASE
 GTCS  OBESITY
 BIPOLAR DISORDER
 LGS
 OCD
 EPILEPTIC  PTSD
ENCEPHALOPATHIE  CHRONIC MIGRAINE
S  ANXIETY DISORDERS
 ATONIC
 ABSENCE

PATIENT SELECTION FOR VNS
 Patients with either generalized or focal onset seizures
without any age restrictions.
 Only pursued following an adequate trial of at least 2
appropriately chosen anti-seizure medications and that
the patient is ineligible for epilepsy surgery
 Patients who have poor adherence or tolerance of anti-
seizure medications may be good candidates for VNS.
 Patients with comorbid depression have been found to
have mood improvements with VNS therapy.
TECHNIQUE ODFVNS
ADVANTAGES & DISADVANTAGES
ADVANTAGES
 Minimize seizures in those
with epilepsy.
 Treat depression.
 Regulate your emotions.
 Reduce blood pressure.
 Lower your heart rate.
 Reduce inflammation.
 Treat migraines and cluster
headaches.
DISADVANTAGES
 Voice changes.
 A hoarse voice.
 Throat pain.
 Cough.
 Headaches.
 Shortness of breath.
 Trouble swallowing.
 Tingling or prickling of the
skin.
THANK YOU