STN

Programming Medtronic Deep Brain
Stimulation Leads In
STN, GPi & Vim Nucleus
(3D Brain Anatomy)
UC201106633aEN
Subthalamic Nucleus
(STN)
STN: Effectively-Placed Bilateral Leads
AXIAL PLANE
Brain
Brain Orientation
Orientation
Zona
incerta
STN
SNc
SNr
Medial
lemniscal
pathway
Red
nucleus
CN III
CN III
nerve roots
nerve roots
Occulomotor
Oculomotor
nucleus
nucleus
ofofCN
CNIIIIII
For comparative purposes:
• Medtronic 3387 DBS shown in left hemisphere, Medtronic 3389 DBS shown in right hemisphere
Anatomy
Preferred Location for DBS Lead
Observed Effect If Stimulated
STN
Dorsolateral aspect of STN
Reduction in parkinsonian symptoms, dyskinesias
STN: Medial Observed Effects
Left hemisphere,
3389 lead,
unipolar contact 0
AXIAL PLANE
Brain Orientation
STN
Stimulation spread
into medial STN and
nerve roots of CN III
Red
nucleus
SNr
SNc
CN III
nerve roots
© Medtronic 2010
Medial
lemniscal
pathway
Oculomotor
nucleus
of CN III
Anatomy
Location Relative To STN
Observed Effect If Stimulated
Nerve roots of CN III
Medial & ventromedial
Diplopia, eye deviation, dizziness, ALO
Red nucleus
Posteromedial
Sweating, nausea, extreme discomfort, paresthesias, warm sensations
Limbic STN
Ventromedial aspect of STN
Possible personality or impulsivity changes, depression
STN: Lateral Observed Effects
Left hemisphere, 3387 lead,
unipolar contact 1
AXIAL PLANE
Brain Orientation
STN
Red
nucleus
SNr
Stimulation spread into fibers
of posterior limb of internal
capsule
Medial
lemniscal
pathway
Oculomotor
nucleus
of CN III
Anatomy
Location Relative To STN
Observed Effect If Stimulated
Corticospinal fibers of internal capsule
Lateral and anterior
Muscle contractions in limbs and body
Corticobulbar fibers of internal capsule
Lateral and anterior
Facial pulling, dysarthria
Frontal eye field fibers of internal capsule
Lateral
Contralateral gaze deviation
STN: Anterior Observed Effects
AXIAL PLANE
Internal capsule
Brain Orientation
Left hemisphere, 3389 lead,
unipolar contact 1
STN
Red
nucleus
Stimulation spread into
posterior limb of internal
capsule
CN III
nerve roots
SNr
Brain Orientation
Anatomy
Location Relative To STN
Observed Effect If Stimulated
Corticospinal fibers of internal capsule
Anterior and lateral
Muscle contractions in limbs and body
Corticobulbar fibers of internal capsule
Anterior and lateral
Facial pulling, dysarthria
Hypothalamus
Very anteromedial
Autonomic symptoms (flushing, sweating)
STN: Posterior Observed Effects
Internal capsule
Left hemisphere, 3387 lead,
unipolar contact 0
AXIAL PLANE
Brain Orientation
Fibers of posterior limb
of internal capsule.
Right hemisphere
fibers not shown
Fibers of medial lemniscal
pathway projecting to Vc
nucleus of thalamus
STN
SNr
Stimulation spread
posteriorly into medial
lemniscus
Red
nucleus
Oculomotor
nucleus
of CN III
Anatomy
Location Relative To STN
Observed Effect If Stimulated
Medial lemniscus
Posterior
Paresthesias (numbness, tingling, electrical sensations)
STN: Superior (Dorsal) Observed Effects
Left hemisphere, 3387 lead,
unipolar contact 1
SAGITTAL PLANE
Brain Orientation
Vop
Vim
Vc
Pulvinar
Voa
Stimulation spread dorsally
into thalamus. Note that
stimulation at contact 0 may
provide some efficacy in
this example.
STN
Fibers of posterior limb
of internal capsule
Red
nucleus
SNr
Anatomy
Location Relative To STN
Observed Effect If Stimulated
Zona incerta
Superior
Possible improvement of dyskinesias and/or tremor
Thalamus
Superior to STN and Zona incerta
Possible improvement of dyskinesias, tremor, muscle tone
Internal capsule
Lateral to STN and Thalamus
Muscle contractions, dysarthria
Point to consider: This example illustrates the DBS lead positioned dorsally along the trajectory path.
STN: Inferior (Ventral) Observed Effects
Left hemisphere, 3389 lead,
unipolar contact 0
AXIAL PLANE
Brain Orientation
STN
Red
nucleus
Stuimulation spread into
SNr
SNr
CN III
nerve roots
Oculomotor
nucleus
of CN III
Medial
lemniscal
pathway
Anatomy
Location Relative To STN
Observed Effect If Stimulated
SNr
Ventral
Possible mood changes, akinesias, depression
Internal capsule fibers
Ventral (not shown above)
Muscle contractions
Globus Pallidus internus
(GPi)
GPi: Effectively-Placed Bilateral Leads
Fibers of posterior limb of
internal capsule
AXIAL PLANE
Brain Orientation
Putamen
GPe
GPi
• Medtronic 3387 DBS leads shown in both hemispheres
Anatomy
Preferred Location for DBS Lead
Observed Effect If Stimulated
GPi
Posteroventral aspect of GPi
Reduction in parkinsonian or dystonia symptoms
Point to consider: The DBS lead may intentionally be placed slightly anterior or lateral in dystonia patients to allow for the use of higher voltages during
programming.
GPi: Medial Observed Effects
CORONAL PLANE
Caudate nucleus
Left hemisphere, 3387 lead,
unipolar contact 0
GPe
GPi
Putamen
Stimulation spread into
posterior limb of
internal capsule
Anatomy
Location Relative To GPi
Observed Effect If Stimulated
Posterior limb of internal capsule
Medial and posterior
Muscle contractions
AXIAL PLANE
Brain Orientation
GPi: Lateral Observed Effects
Left hemisphere, 3387 lead,
unipolar contact 1
Caudate nucleus
AXIAL PLANE
Brain Orientation
Putamen
GPe
GPi
Stimulation spread is primarily
within GPe
Anatomy
Location Relative To GPi
Observed Effect If Stimulated
GPe
Lateral and anterior
No effect (possible improvement in PD symptoms)
Putamen
Lateral and anterior to GPe
No effect
GPi: Anterior Observed Effects
Left hemisphere, 3387 lead,
unipolar contact 0
Caudate nucleus
AXIAL PLANE
Putamen
Brain Orientation
GPe
GPi
Stimulation spread is
primarily
within GPe
Anatomy
Location Relative To GPi
Observed Effect If Stimulated
GPe
Lateral and anterior
No effect (possible improvement in PD symptoms)
Putamen
Lateral and anterior to GPe
No effect
GPi: Posterior Observed Effects
CORONAL PLANE
Putamen
AXIAL PLANE
Brain Orientation
Left hemisphere, 3387 lead,
unipolar contact 0
GPe
GPi
Contact 0 protruding
from base of GPi
Stimulation spread into
posterior limb of
internal capsule
Anatomy
Location Relative To GPi
Observed Effect If Stimulated
Posterior limb of internal capsule
Medial & posterior
Muscle contractions
GPi: Superior (Dorsal) Observed Effects
AXIAL PLANE
Brain Orientation
Putamen
Caudate
nucleus
Left hemisphere, 3387 lead,
unipolar contact 0
GPe
GPi
Stimulation spread
into GPe
Optic tract
Anatomy
Location Relative To GPi
Observed Effect If Stimulated
GPe
Lateral and anterior
Possible improvement in PD symptoms or no effect
Putamen
Lateral and anterior to GPe
No effect
Point to consider: This example illustrates the DBS lead positioned dorsally along the trajectory path.
GPi: Inferior (Ventral) Observed Effects
AXIAL PLANE
Caudate nucleus
Left hemisphere, 3387 lead,
unipolar contact 0
Putamen
GPe
Brain Orientation
GPi
Right orbit
Optic chiasm
Stimulation spread into
left optic tract
Anatomy
Location Relative To GPi
Observed Effect If Stimulated
Optic tract
Inferior
Phosphenes (‘flashing lights’) in contralateral visual hemifield
Ventralis intermedius (Vim)
Nucleus of the Thalamus
Vim: Effectively-Placed Unilateral Lead
SAGITTAL PLANE
AXIAL PLANE
Brain Orientation
Internal capsule
Fibers of posterior limb of
internal capsule coursing
lateral to Vim
Voa
Vop
Vim
Vc
Pulvinar
STN
• Medtronic 3387 DBS lead shown in left hemisphere
Anatomy
Preferred Location for DBS Lead
Observed Effect If Stimulated
Vim
Middle of nucleus, DBS tip 1-2 mm anterior to VC border, contact 0 at base of Vim
Tremor arrest
Point to consider: The Vim nucleus is somatotopically organized along a medial-lateral axis. Face/tongue representation is medial, foot is lateral.
Vim: Medial Observed Effects
Axial MRI at level
of ACPC plane
(ACPC plan visible
as yellow lines)
Left hemisphere, 3387 lead,
unipolar contact 0
AXIAL PLANE
Brain Orientation
Voa
Fibers of anterior limb
of internal capsule
Anterior
nucleus
Lateral
dorsal
nucleus
Vop
Vim
Fibers of posterior limb
of internal capsule
Lateral
posterior
nucleus
Vc
Pulvinar
Stimulation spread within
medial thalamic nuclei
Anatomy
Location Relative To Vim
Observed Effect If Stimulated
Medial Vim
Medial aspect of nucleus
Possible dysarthria in addition to tremor control
CM/Pf
Medial
No effect
Vim: Lateral Observed Effects
Internal capsule
AXIAL PLANE
Left hemisphere, 3387 lead,
unipolar contact 0
Brain Orientation
Voa
Vop
Fibers of posterior limb of
internal capsule
Vim
Vc
Stimulation spread into
internal capsule
Anatomy
Location Relative To Vim
Observed Effect If Stimulated
Posterior limb of internal capsule
Lateral
Dysarthria, facial pulling, muscle contractions
Point to consider: The internal capsule is somatotopically organized along an
anterior-posterior axis. Face representation is anterior, foot is posterior.
Vim: Anterior Observed Effects
Internal capsule
AXIAL PLANE
Brain Orientation
Voa
Vop
Vim
Vc
© Medtronic 2010
Anatomy
Location Relative To Vim
Observed Effect If Stimulated
Vop
Anterior
Possible reduction in tremor at voltages higher than typically used in Vim
Voa
Anterior to Vop
No effect
Vim: Posterior Observed Effects
SAGITTAL PLANE
AXIAL PLANE
Left hemisphere, 3387 lead,
unipolar contact 0
Brain Orientation
Voa
Vop
Vim
Vc
Pulvinar
Stimulation spread within
Vc nucleus
Anatomy
Location Relative To Vim
Observed Effect If Stimulated
Vc nucleus
Posterior
Paresthesias that increase in severity with increasing voltage
Points to consider: The Vc nucleus is somatotopically organized along a medial-lateral axis.
Face/tongue representation is medial, foot is lateral. Transient paresthesias do not necessarily
indicate a lead that is too posterior.
Vim: Superior (Dorsal) Observed Effects
AXIAL PLANE
Right hemisphere
Internal capsule
Left hemisphere, 3387 lead,
unipolar contact 0
AXIAL PLANE
Brain Orientation
Lateral dorsal
nucleus
Fibers of posterior limb
of internal capsule
Voa
Vop
Stimulation spread
into dorsal Vop/Vim
Vim
Pulvinar
Vc
Anatomy
Location Relative To Vim
Observed Effect If Stimulated
Dorsal thalamic nuclei
Dorsal
No effect
Dorsal Vop/Vim
Dorsal aspect
Possible decrease in tremor at higher voltages
Internal capsule
Lateral and dorsal
Dysarthria, muscle contractions
Point to consider: This example illustrates the DBS lead positioned dorsally along the trajectory path.
Vim: Inferior (Ventral) Observed Effects
SAGITTAL PLANE
Brain Orientation
Voa
Vop
Vim
Vc
STN
Anatomy
Location Relative To Vim
Observed Effect If Stimulated
Brachium conjunctivum (cerebellar fibers)
Ventral and medial
Ataxia
Zona incerta
Ventral
Possible improvement in dyskinesias and/or tremor
Medial lemniscal pathway
Ventral and posterior
Paresthesias
Internal capsule
Ventral and lateral
Dysarthria, muscle contractions
Acronym Legend & Disclaimer Statement
AC/PC
ALO
CM/Pf
CN
GPe
GPi
SNc
SNr
STN
Vc
Vim
Voa
Vop
ZI
Anterior Commissure / Posterior Commissure
Apraxia of eyelid opening
Centromedian/Parafascicular Complex
Cranial Nerve
Globus Pallidus externus
Globus Pallidus internus
Substantia nigra pars compacta
Substantia nigra pars reticulata
Subthalamic Nucleus
Ventralis caudalis nucleus
Ventralis intermedius
Ventralis oralis anterior nucleus
Ventralis oralis posterior nucleus
Zona Incerta
Disclaimer Statement: The effects of stimulation due to sub-optimal lead placement in
this presentation are for reference and training purposes only. Side effects observed may
be the result of incorrect stimulation parameters being applied in addition to, or instead of,
a misplaced lead. Consider orientation of the DBS lead within the brain when determining
a stimulation strategy (for example, dorsal lead contacts are always more anterior and
typically more lateral within the brain than ventral lead contacts).
These slides were designed with input from the following sources:
Israel Z, Burchiel KJ. Microelectrode Recording in Movement Disorder Surgery. New York, NY: Thieme Medical
Publishers Inc.; 2004
Montgomery EB Jr. Deep Brain Stimulation Programming: Principles and Practice. New York, NY: Oxford
University Press; 2010
Wang D, Sanchez J, Foote KD, Sudhyadhom A, Tariq Bhatti M, Lewis S, Okun M. Failed DBS for palliation of
visual problems in a case of oculopalatal tremor. Parkinsonism & Related Disorders, 71-73 (15:1), 2009
Rodriguez-Oroz MC, Rodriguez M, Leiva C, Rodriguez-Palmero M, Nieto J, Garcia-Garcia D, Zubieta JL, Cardiel
C, Obeso JA. Neuronal activity of the red nucleus in Parkinson’s disease. Mov Disorders, 908-911 (23:6), 2008
Krack P, Fraix V, Mendes A, Benabid AL, Pollak P. Postoperative management of subthalamic nucleus
stimulation. Mov Disorders, S188-S197 (17:S3), 2002
Tarsey D, Vitek JL, Lozano AM. Surgical Treatment of Parkinson’s Disease and Other Movement Disorders.
Totowa, NJ: Humana Press; 2003
Baltuch GH, Stern MB. Deep Brain Stimulation for Parkinson’s Disease. New York, NY: Informa Healthcare;
2007
Vitek JL, Hashimoto T, Peoples J, DeLong MR, Bakay RAE. Acute stimulation in the external segment of the
globus pallidus improves parkinsonian motor signs. Mov Disorders, 907-915 (19:8), 2004
Bakay RAE. Movement Disorders – The Essentials. New York, NY: Thieme Medical Publishers Inc.; 2009
Tarsey D, Vitek JL, Starr PA, Okun MS. Deep Brain Stimulation in Neurological and Psychiatric Disorders.
Totowa, NJ: Humana Press; 2008
3D DBS Simulator developed by Kirk W. Finnis for Medtronic
Disclosure Statement
Medtronic DBS Therapy for Parkinson’s Disease, Tremor, and Dystonia: Product technical manual must be reviewed prior to use for
detailed disclosure.
Indications:
Medtronic DBS Therapy for Parkinson’s Disease: Bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) using
Medtronic DBS Therapy for Parkinson’s Disease is indicated for adjunctive therapy in reducing some of the symptoms of advanced, levodoparesponsive Parkinson’s disease that are not adequately controlled with medication.
Medtronic DBS Therapy for Tremor: Unilateral thalamic stimulation using Medtronic DBS Therapy for Tremor is indicated for the suppression of
tremor in the upper extremity. The system is intended for use in patients who are diagnosed with Essential Tremor or Parkinsonian tremor not
adequately controlled by medications and where the tremor constitutes a significant functional disability. The safety or effectiveness of this therapy has
not been established for bilateral stimulation.
Medtronic DBS Therapy for Dystonia: Unilateral or bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) using
Medtronic DBS Therapy for Dystonia is indicated as an aid in the management of chronic, intractable (drug refractory) primary dystonia, including
generalized and segmental dystonia, hemidystonia, and cervical dystonia (torticollis), for individuals 7 years of age and older.
Contraindications: Contraindications include patients who will be exposed to MRI using a full body transmit radio-frequency (RF) coil, a receive-only
head coil, or a head transmit coil that extends over the chest area, patients who are unable to properly operate the neurostimulator, or for Parkinson’s
disease and Essential Tremor, patients for whom test stimulation is unsuccessful. Also, diathermy (e.g., shortwave diathermy, microwave diathermy or
therapeutic ultrasound diathermy) is contraindicated because diathermy's energy can be transferred through the implanted system (or any of the
separate implanted components), which can cause neurostimulation system or tissue damage and can result in severe injury or death. Transcranial
Magnetic Stimulation (TMS) is contraindicated for patients with an implanted DBS System.
Warnings/ Precautions/Adverse Events: There is a potential risk of tissue damage using stimulation parameter settings of high amplitudes and wide
pulse widths. Extreme care should be used with lead implantation in patients with a heightened risk of intracranial hemorrhage. The lead-extension
connector should not be placed in the soft tissues of the neck due to an increased incidence of lead fracture. Theft detectors and security screening
devices may cause stimulation to switch ON or OFF, and may cause some patients to experience a momentary increase in perceived stimulation.
Although some MRI procedures can be performed safely with an implanted DBS System, clinicians should carefully weigh the decision to use MRI in
patients with an implanted DBS System. MRI can cause induced voltages in the neurostimulator and/or lead possibly causing uncomfortable, jolting,
or shocking levels of stimulation.
Disclosure Statement
The DBS System may be affected by or adversely affect medical equipment such as cardiac pacemakers or therapies,
cardioverter/ defibrillators, external defibrillators, ultrasonic equipment, electrocautery, or radiation therapy. Safety and
effectiveness has not been established for patients with neurological disease other than Parkinson’s disease or Essential
Tremor, previous surgical ablation procedures, dementia, coagulopathies, or moderate to severe depression; patients who are
pregnant; patients under 18 years; and patients over 80 years of age for Medtronic DBS Therapy for Tremor. For patients with
Dystonia, age of implant is suggested to be that at which brain growth is approximately 90% complete or above. Depression,
suicidal ideations and suicide have been reported in patients receiving Medtronic DBS Therapy for Movement Disorders,
although no direct cause and effect relationship has been established.
Abrupt cessation of stimulation should be avoided as it may cause a return of disease symptoms, in some cases with intensity
greater than was experienced prior to system implant (“rebound” effect). Adverse events related to the therapy, device, or
procedure can include: stimulation not effective, cognitive disorders, pain, dyskinesia, dystonia, speech disorders including
dysarthria, infection, paresthesia, intracranial hemorrhage, electromagnetic interference, cardiovascular events, visual
disturbances, sensory disturbances, device migration, paresis/asthenia, abnormal gait, incoordination, headaches, lead
repositioning, thinking abnormal, device explant, hemiplegia, lead fracture, seizures, respiratory events, and shocking or jolting
stimulation. Patients using a rechargeable neurostimulator for Parkinson’s Control Therapy or Tremor Control Therapy should
check for skin irritation or redness near the neurostimulator during or after recharging, and contact their physician if symptoms
persist.
Humanitarian Device (Dystonia): Authorized by Federal Law for the use as an aid in the management of chronic, intractable
(drug refractory) primary dystonia, including generalized and segmental dystonia, hemidystonia, and cervical dystonia (torticollis),
for individuals 7 years of age and older. The effectiveness of this device for this use has not been demonstrated.
USA Rx only
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