Andre Morsnowski

Most effective stimulation site in subthalamic deep brain stimulation for Parkinson's disease

The optimal stimulation site in subthalamic deep brain stimulation (STN‐DBS) was evaluated by correlation of the stereotactic position of the stimulation electrode with the electrophysiologically specified dorsal STN border. In a series of 25 electrodes, best clinical results with least energy consumption were found in contacts located in the dorsolateral border zone, whereas contacts within the subthalamic white matter, e.g., zona incerta, were significantly less effective. We suggest that the dorsolateral STN border should be covered by STN‐DBS.

Measuring the Refractoriness of the Electrically Stimulated Auditory Nerve

Intracochlear recordings in cochlear implant recipients provide access to the electrically evoked compound action potential (ECAP). ECAP thresholds are potential predictors of speech processor map’s threshold and comfortable loudness levels. The auditory nerve’s refractory properties can influence these levels due to high-rate stimulation with interpulse intervals within the relative refractory period. Recovery functions were investigated at 84 stimulation sites in 14 Nucleus CI24 recipients using neural response telemetry and a modified forward masking technique. This technique introduces a reference masker-probe interval (MPI). In our study, an appropriate value between 300 and 375 µs was determined for this reference MPI, and the use of a reference MPI of 300 µs is suggested for recovery and amplitude growth functions. A median absolute refractory period of about 390 µs and a median time constant of about 425 µs were obtained by fitting an exponential model to the data. Hence, the auditory nerve is usually in relative refractory state when standard neural response telemetry forward masking is selected because of its default MPI of 500 µs. This can bias the measurement of ECAP thresholds. Additionally, the shape of standard forward masking recovery functions was explained by the influence of latency shift of the neural response.

Clinical results of AutoNRT, a completely automatic ECAP recording system for cochlear implants.

Objective: AutoNRT™ is the completely automatic electrically evoked compound action potential (ECAP) measuring algorithm in the recently released Nucleus Freedom cochlear implant system. AutoNRT allows clinicians to automatically record T-NRT profiles that in turn can be used as a guide for initial fitting. The algorithm consists of a pattern recognition part that judges if the traces contain an ECAP and an intelligent flow that optimizes the measurement parameters and finds the ECAP threshold (T-NRT). The objective of this study was to determine how accurate, reliable, and fast the automatic measurements are. Design: Data on more than 400 electrodes were collected as part of the multicenter clinical trial of the Nucleus Freedom cochlear implant system. T-NRT values determined by the algorithm were compared with T-NRT determinations on the same data by different human observers. Also, the time the measurements took was analyzed. Results: In 90% of the cases, the absolute difference between the AutoNRT and the human observer determined T-NRT was less than 9 CL; the median absolute difference was 3 CL. A second experiment, in which a group of human observers were asked to analyze NRT data, showed high variability in T-NRT; in some cases, two experienced clinicians disagreed by more than 30 current levels. Compared with the group, AutoNRT performed as well as the “average” clinician, with the advantage that the AutoNRT threshold determinations are objective. Analysis of the timing data showed an average intraoperative measurement time of less than 20 sec per electrode with a standard deviation of 5 sec, suggesting that the total array of 22 electrodes can be measured intraoperatively in about 7 minutes on average. Conclusions: AutoNRT provides comparable accuracy to an average clinician but with the added benefit of significant time savings over manual recordings. This makes it a valuable tool for clinical measurement of ECAP threshold in cochlear implant recipients.

Is the rhythm of physiological tremor involved in cortico-cortical interactions?

The function of low‐frequency oscillations as correlates of physiological tremor in supplementary motor area (SMA) and M1 remains unclear. In epicortical recordings from M1 and SMA and surface electromyographic (EMG) recordings in an epileptic patient we found reproducibly significant coherence between all three recording sites in the 6‐ to 15‐Hz band. The partial coherence between SMA and muscle, however, was not significant. There was a constant phase shift between SMA and M1 indicating synchronized activity. We conclude that the cortical correlates of physiological tremor may be involved in linking different cortical motor centers and might therefore play a role in cortical motor planning.

Verbesserung der Sprachverständlichkeit durch neuen Cochlear-Implant-Sprachprozessor

The aim of this multicenter clinical field study was to assess the benefits of the new Freedom 24 sound processor for cochlear implant (CI) users implanted with the Nucleus 24 cochlear implant system. The study included 48 postlingually profoundly deaf experienced CI users who demonstrated speech comprehension performance with their current speech processor on the Oldenburg sentence test (OLSA) in quiet conditions of at least 80% correct scores and who were able to perform adaptive speech threshold testing using the OLSA in noisy conditions. Following baseline measures of speech comprehension performance with their current speech processor, subjects were upgraded to the Freedom 24 speech processor. After a take-home trial period of at least 2 weeks, subject performance was evaluated by measuring the speech reception threshold with the Freiburg multisyllabic word test and speech intelligibility with the Freiburg monosyllabic word test at 50 dB and 70 dB in the sound field. The results demonstrated highly significant benefits for speech comprehension with the new speech processor. Significant benefits for speech comprehension were also demonstrated with the new speech processor when tested in competing background noise.In contrast, use of the Abbreviated Profile of Hearing Aid Benefit (APHAB) did not prove to be a suitably sensitive assessment tool for comparative subjective self-assessment of hearing benefits with each processor. Use of the preprocessing algorithm known as adaptive dynamic range optimization (ADRO) in the Freedom 24 led to additional improvements over the standard upgrade map for speech comprehension in quiet and showed equivalent performance in noise. Through use of the preprocessing beam-forming algorithm BEAM, subjects demonstrated a highly significant improved signal-to-noise ratio for speech comprehension thresholds (i.e., signal-to-noise ratio for 50% speech comprehension scores) when tested with an adaptive procedure using the Oldenburg sentences in the clinical setting S(0)N(CI), with speech signal at 0 degrees and noise lateral to the CI at 90 degrees . With the convincing findings from our evaluations of this multicenter study cohort, a trial with the Freedom 24 sound processor for all suitable CI users is recommended. For evaluating the benefits of a new processor, the comparative assessment paradigm used in our study design would be considered ideal for use with individual patients.

Parkinsonian action tremor: Interference with object manipulation and lacking levodopa response

It has been postulated that Parkinsonian action tremor is distinct from classical resting tremor and that it may contribute to a loss of manual dexterity in Parkinsons disease. We analyzed pinch grip coordination in 20 patients with Parkinsons disease. An object with and without an additional 500 g weight was grasped, lifted and held for a short time with opposed thumb and index finger. Force sensors recorded the force exerted by both fingers. Spectral analysis of the force traces was performed. Transition times between grasping and lifting the object were measured. 18 age matched normal volunteers served as a control group. While holding the object, there were force oscillations in the 3.5-6.5 Hz band indicating (reemerging) classical Parkinsonian tremor in 65% of the patients. This was reduced to 15-20% under levodopa. Oscillations in the 6-15 Hz band were found in 30% (50% with weight) of the patients, remaining unchanged under levodopa, and in 10% (20% with weight) of the normal controls. During lift initiation, 6-15 Hz oscillations were found in all patients and the majority of controls. The band power was positively correlated with the movement transition times in the severely akinetic patients and was significantly higher than in controls. It remained unchanged under levodopa. Our data confirm that Parkinsonian action tremor activated during complex voluntary movements is distinct from classical resting tremor. It does not show a clear levodopa response but affects dextrous movement coordination when associated with clinically severe overall akinesia.

Effect of changing pulse rate on profile parameters of perceptual thresholds and loudness comfort levels and relation to ECAP thresholds in recipients of the Nucleus CI24RE device.

Abstract The Nucleus CI24RE ‘Freedom’ device offers higher stimulation rates and lower noise levels in action potential measurements (ECAPs) than previous devices. A study including ten European implant teams showed that the effect of changes in rate from 250 to 3500 pulses per second on tilt and curvature of the T and C profiles is insignificant. When changing rate one may change the levels at all electrodes by the same amount. Using an automated procedure ECAPs could be measured quickly and reliably at a noise level of only 1 μV. However, this did not result in improved correlations between the tilt and curvature parameters of the ECAP profiles and those of the T and C profiles. Average C levels appear to differ markedly among implant centers; a better assessment protocol is required. When increasing stimulus rate one should take into account that this requires higher pulse charges per second and more power consumption. Sumario El dispositivo Nucleus CI24RE “Freedom” ofrece tasas de estimulación mayores, y menores niveles de ruido en las mediciones del potencial de acción (ECAPs) que los dispositivos anteriores. Un estudio que incluyó diez grupos europeos de implantes, mostró que el efecto de los cambios en la tasa de 250 a 3500 pulsos por segundo en la inclinación y la curvatura de los perfiles T y C es insignificante. Cuando se cambian las tasas, uno puede cambiar los niveles de todos los electrodos en la misma medida. Utilizando un procedimiento automatizado, los ECAPs pueden medirse en forma rápida y confiable a un nivel de ruido de solo 1mV. Sin embargo, esto no conlleva (a) una mejoría en las correlaciones entre los parámetros de inclinación y de curvatura de los perfiles ECAP y aquellos de los perfiles de T y C. Los niveles C promedio parecen diferir marcadamente entre los centros de implante; se requiere un mejor protocolo de evaluación. Cuando se incrementa la tasa de estimulación uno debe tomar en cuenta que eso requiere una mayor carga de pulsos por segundo y mayor poder de consumo.

Improving speech comprehension using a new cochlear implant speech processor

The aim of this multicenter clinical field study was to assess the benefits of the new Freedom 24 sound processor for cochlear implant (CI) users implanted with the Nucleus 24 cochlear implant system. The study included 48 postlingually profoundly deaf experienced CI users who demonstrated speech comprehension performance with their current speech processor on the Oldenburg sentence test (OLSA) in quiet conditions of at least 80% correct scores and who were able to perform adaptive speech threshold testing using the OLSA in noisy conditions. Following baseline measures of speech comprehension performance with their current speech processor, subjects were upgraded to the Freedom 24 speech processor. After a take-home trial period of at least 2 weeks, subject performance was evaluated by measuring the speech reception threshold with the Freiburg multisyllabic word test and speech intelligibility with the Freiburg monosyllabic word test at 50 dB and 70 dB in the sound field. The results demonstrated highly significant benefits for speech comprehension with the new speech processor. Significant benefits for speech comprehension were also demonstrated with the new speech processor when tested in competing background noise.In contrast, use of the Abbreviated Profile of Hearing Aid Benefit (APHAB) did not prove to be a suitably sensitive assessment tool for comparative subjective self-assessment of hearing benefits with each processor. Use of the preprocessing algorithm known as adaptive dynamic range optimization (ADRO) in the Freedom 24 led to additional improvements over the standard upgrade map for speech comprehension in quiet and showed equivalent performance in noise. Through use of the preprocessing beam-forming algorithm BEAM, subjects demonstrated a highly significant improved signal-to-noise ratio for speech comprehension thresholds (i.e., signal-to-noise ratio for 50% speech comprehension scores) when tested with an adaptive procedure using the Oldenburg sentences in the clinical setting S(0)N(CI), with speech signal at 0 degrees and noise lateral to the CI at 90 degrees . With the convincing findings from our evaluations of this multicenter study cohort, a trial with the Freedom 24 sound processor for all suitable CI users is recommended. For evaluating the benefits of a new processor, the comparative assessment paradigm used in our study design would be considered ideal for use with individual patients.

Das Refraktärverhalten des elektrisch stimulierten Hörnervs

INTRODUCTION Electrically evoked compound action potentials (TECAP) of the auditory nerve can be recorded in cochlear implants. TECAP thresholds are used to predict threshold levels for speech processor maps. The auditory nerves refractory properties can influence these levels. METHODS Recovery functions were investigated at 84 stimulation sites in 14 patients who had Nucleus CI24 implants; neural response telemetry (NRT) and a modified forward-masking technique were used for these investigations, introducing the reference masker-probe interval (MPI). RESULTS AND CONCLUSION An interval between 300 and 375 micros was found to be suitable as the reference MPI in our study. The median of the absolute refractory period was determined as 390 s and the median time constant of the recovery function, at 425 s. In practice, a reference MPI of 300 s is suggested for measurement of recovery and amplitude growth functions. As up to now the amplitude growth function has been measured at 500 s and thus mostly in a relatively refractory condition, the refractory behaviour should influence the TNRT. In addition, it was possible to explain the shape of standard forward-masking recovery functions with reference to the latency shift of the neural response.

Refractory behaviour of the electrically stimulated auditory nerve

INTRODUCTION Electrically evoked compound action potentials (TECAP) of the auditory nerve can be recorded in cochlear implants. TECAP thresholds are used to predict threshold levels for speech processor maps. The auditory nerves refractory properties can influence these levels. METHODS Recovery functions were investigated at 84 stimulation sites in 14 patients who had Nucleus CI24 implants; neural response telemetry (NRT) and a modified forward-masking technique were used for these investigations, introducing the reference masker-probe interval (MPI). RESULTS AND CONCLUSION An interval between 300 and 375 micros was found to be suitable as the reference MPI in our study. The median of the absolute refractory period was determined as 390 s and the median time constant of the recovery function, at 425 s. In practice, a reference MPI of 300 s is suggested for measurement of recovery and amplitude growth functions. As up to now the amplitude growth function has been measured at 500 s and thus mostly in a relatively refractory condition, the refractory behaviour should influence the TNRT. In addition, it was possible to explain the shape of standard forward-masking recovery functions with reference to the latency shift of the neural response.