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  • Review Article
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Technology of deep brain stimulation: current status and future directions

Nature Reviews Neurology volume 17, pages 75–87 (2021)Cite this article

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Abstract

Deep brain stimulation (DBS) is a neurosurgical procedure that allows targeted circuit-based neuromodulation. DBS is a standard of care in Parkinson disease, essential tremor and dystonia, and is also under active investigation for other conditions linked to pathological circuitry, including major depressive disorder and Alzheimer disease. Modern DBS systems, borrowed from the cardiac field, consist of an intracranial electrode, an extension wire and a pulse generator, and have evolved slowly over the past two decades. Advances in engineering and imaging along with an improved understanding of brain disorders are poised to reshape how DBS is viewed and delivered to patients. Breakthroughs in electrode and battery designs, stimulation paradigms, closed-loop and on-demand stimulation, and sensing technologies are expected to enhance the efficacy and tolerability of DBS. In this Review, we provide a comprehensive overview of the technical development of DBS, from its origins to its future. Understanding the evolution of DBS technology helps put the currently available systems in perspective and allows us to predict the next major technological advances and hurdles in the field.

Key points

  • Deep brain stimulation (DBS) is a neurosurgical procedure that allows targeted circuit-based neuromodulation and is commonly used for the treatment of movement disorders such as Parkinson disease, tremor and dystonia.

  • Innovations in the field of cardiac pacemakers have enabled pulse generators for DBS to evolve from external devices to small rechargeable, implantable devices.

  • With directional DBS leads, the current can be directed or shaped to personalize stimulation to individual anatomical structures.

  • Closed-loop DBS systems simultaneously record and stimulate neural activity, allowing the stimulation to be adjusted according to disease-specific neural biomarkers.

  • Open-access software can be used to localize DBS electrodes and, on the basis of the stimulation parameters, to model the volume of tissue activated around the electrodes, shedding light on key neurocircuitry elements.

  • As DBS systems become compatible with wireless networks, remote programming by physicians will become possible but privacy issues will also need to be addressed to prevent misuse, including ‘brainjacking’.

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Fig. 1: Timeline of technology development for DBS.
Fig. 2: DBS electrode configurations.
Fig. 3: Stimulation waveform shapes and temporal stimulation patterns.
Fig. 4: Adaptive DBS in Parkinson disease.
Fig. 5: DBS neuroimaging.
Fig. 6: Future visions for DBS.

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Acknowledgements

The work on this manuscript was supported by an unconditional grant of the World Society for Stereotactic and Functional Neurosurgery (WSSFN). The working process was coordinated with the Research and Education committees of the WSSFN.

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Authors and Affiliations

  1. Department of Neurosurgery, Hannover Medical School, Hannover, Germany

    Joachim K. Krauss & Jens Volkmann

  2. Department of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Nir Lipsman & Benjamin Davidson

  3. Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

    Tipu Aziz

  4. Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada

    Alexandre Boutet

  5. Medical Research Council Brain Network Dynamics Unit, University of Oxford, Oxford, UK

    Peter Brown

  6. Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea

    Jin Woo Chang

  7. Department of Biomedical Engineering, Duke University, Durham, NC, USA

    Warren M. Grill

  8. Department of Clinical Neuroscience, University of Umea, Umea, Sweden

    Marwan I. Hariz

  9. Department of Neurology, Movement Disorders and Neuromodulation Section, Charité Medicine University of Berlin, Berlin, Germany

    Andreas Horn

  10. Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA

    Michael Schulder

  11. Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA

    Antonios Mammis

  12. Department of Neurosurgery, Stanford University, Stanford, CA, USA

    Peter A. Tass

  13. Department of Neurology, University Hospital of Würzburg, Würzburg, Germany

    Jens Volkmann

  14. Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Andres M. Lozano

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  1. Joachim K. Krauss
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  9. Marwan I. Hariz
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  15. Andres M. Lozano
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All authors contributed to all aspects of manuscript preparation.

Corresponding author

Correspondence to Andres M. Lozano.

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Competing interests

J. K. K. is a consultant for Medtronic and Boston Scientific. P. B. is a consultant for Medtronic. W. M. G. is the Director, Chief Scientific Officer and share owner of Deep Brain Innovations, LLC. He also receives royalty payments for licensed patents on temporal patterns of deep brain stimulation. M. I. H. has received travel expenses and honoraria from Boston Scientific for speaking at meetings. A. H. was supported by the German Research Council (DFG grant 410169619) and reports lecture fees from Medtronic and Boston Scientific unrelated to the present work. P. A. T. works as a consultant for Boston Scientific Neuromodulation. J. V. works as a consultant to Boston Scientific, Medtronic, and Newronika and has received honoraria for lectures from Boston Scientific and Medtronic as well as research grants from Boston Scientific and Medtronic. A. M. L. has served as a consultant for Boston Scientific, Medtronic, Aleva, and Abbott and is a co-founder of Functional Neuromodulation. All other authors declare no competing interests.

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Nature Reviews Neurology thanks V. Visser-Vandewalle and Y. Temel for their contribution to the peer review of this work.

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Glossary

Brainjacking

The unauthorized control of an implanted brain device, theoretically through Bluetooth or wireless internet technology.

Gate theory

Theory describing the ‘gating’ of pain signals, whereby the transmission of non-painful stimuli can block or override painful signals at the level of the spinal cord.

Quadripolar electrodes

Deep brain stimulation (DBS) electrodes configured with four equally spaced contacts — the most commonly used DBS electrode configuration.

Radiofrequency coupled coils

Early deep brain stimulation systems powered the delivery of stimulation using an implanted radiofrequency receiving coil. These systems evolved and were replaced by the modern-day battery-coupled pulse generators.

Implantable pulse generator

(IPG). A battery, typically implanted below the clavicle and connected via subcutaneous extension cables to intracranial electrodes. The IPG generates and transmits electrical impulses at a specified frequency, amplitude and pulse width.

Parameter space

The available combinations of voltage, current, pulse width, contact selection, current shape and stimulation pattern when programming a deep brain stimulation device.

Segmented leads

Deep brain stimulation electrodes with multiple different contacts through which current can be transmitted.

Electrode contacts

Non-insulated regions near the distal tip of an electrode from which electrical impulses are transmitted.

Waveforms

The shapes of the electrical impulses transmitted from a deep brain stimulation contact, most often represented in 2D as a function of voltage or current over time.

Volume of tissue activated

(VTA). The estimated spatial extent of the electric field surrounding an activated deep brain stimulation contact at a given stimulation parameter setting.

Energy-harvesting

Having the capability to capture energy from the surrounding environment, including from thermal, vibratory, electromagnetic and acoustic sources.

Biphasic pulses

Electrical impulses consisting of both a positively and a negatively charged component. During each stimulus, a reversal between cathodic and anodic stimulation occurs.

Cathodic and anodic

During stimulation, an electrode contact can function as a cathode (or current sink) or as an anode (source of current) relative to the implantable pulse generator or to other electrode contacts.

Spike timing-dependent plasticity

Concept by which the timing of presynaptic and postsynaptic excitatory potentials affects the overall synaptic strength.

Neuronal coincidence rates

The incidence of temporally overlapping presynaptic and postsynaptic excitatory potentials.

Power spectra

In the context of local field potentials, it refers to the strength or intensity of the electric field based on frequency, commonly categorized as delta (1–3 Hz), theta (4–8 Hz), alpha (4–9 Hz), beta (15–30 Hz) and gamma (>30 Hz).

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Krauss, J.K., Lipsman, N., Aziz, T. et al. Technology of deep brain stimulation: current status and future directions. Nat Rev Neurol 17, 75–87 (2021). https://doi.org/10.1038/s41582-020-00426-z

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