PMC6041971_01
(A,B) Patient's attempt at drawing a spiral prior to DBS implantation and after implantation with activation of the following parameter: 2B (-), 2A (+), 2C (+). This is theoretically further extending stimulation into the adjacent ZI as well as maintaining stimulation in the STN.
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F2
His symptoms also began to severely impact his guitar playing ability and handwriting (Figure 2A). His writing spirals normalized (Figure 2B) and he was able to play guitar unencumbered in the operating room.
(A) Final bipolar directional montage on a single segmented contact: 2B cathode (-), 2A anode (+), 2C anode (+) (1.4 mA, rate 160 Hz, pulse width 60 mus). (B) Intraoperative imaging showing lead position and adjacent anatomy. IC, internal capsule; STN, Subthalamic Nucleus; ZI, Zona Incerta; RN, Red Nucleus; Red circle, representation of lead position; Yellow bars, representation of directional contacts.
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F3
Next, the montage 2B cathode (-), 2A anode (+), 2C anode (+) was tried, envisioning a "tear-drop" shaped stimulation, activating the area adjacent to the bore of the electrode on the 2 level given anode activation (STN), and stimulation extending posterior and medial through the cathode activation at 2B, activating the ZI (Figures 3A,B). Considering the possibility of single contact bipolar directional stimulation, we then attempted and found full kinetic tremor resolution as well as normalization of his right lateralizing akinesia and rigidity and resting tremor at the montage 2B cathode (-), 2A anode (+), 2C anode (+) (1.4 mA, rate 160 Hz, pulse width 60 mus) (Figures 3A,B).