Current and future applications of local field potential-guided programming for Parkinson’s disease with the Percept™ rechargeable neurostimulator

Deep brain stimulation (DBS) has been established as an effective neuromodulatory treatment for Parkinson’s disease (PD) with motor complications or refractory tremor. Various DBS devices with unique technology platforms are commercially available and deliver continuous, open-loop stimulation. The Percept™ family of neurostimulators use BrainSense™ technology with five key features to sense local field potentials while stimulating, enabling integration of physiologic data into the routine practice of DBS programming. The newly approved Percept™ rechargeable RC implantable pulse generator offers a smaller, thinner design and reduced recharge time with prolonged recharge interval. In this review, we describe the application of local field potential sensing-based programming in PD and highlight the potential future clinical implementation of closed-loop stimulation using the Percept™ RC implantable pulse generator. Deep brain stimulation (DBS) is indicated for managing motor complications or refractory tremor in advanced Parkinson’s disease (PD). DBS devices consist of three components: electrodes, extension wires and implanted pulse generators (IPGs). The use of a rechargeable device may vary depending on patient characteristics (e.g., age, disease being treated, access to the treatment center, comfort with or preference regarding charging procedures, prior experience with non rechargeable IPGs). The Percept™ family of IPGs (Medtronic, Minneapolis, MN 55432, USA) was the first commercially available bi-directional interface capable of recording brain signals in the form of local field potentials (LFPs) and delivering stimulation for DBS. Beta frequency LFPs in PD correlate best to rigidity and bradykinesia and are suppressible after treatment with levodopa or DBS. LFP sensing and data streaming in conjunction with stimulation delivery require higher energy expenditure than nonsensing devices, resulting in shorter battery longevity in non rechargeable devices. The Percept™ RC neurostimulator is the first commercially available simultaneous sensing and stimulating device with rechargeability. BrainSense™ technology consists of five features including LFP survey, signal test, streaming, timeline and event recording, which can facilitate DBS programming by supporting contact selection, assessment of clinical response to stimulation, stimulation optimization and symptom characterization in PD. Adaptive DBS (aDBS) uses the LFP power as a control mechanism to automatically adjust DBS settings according to an individual patient’s physiologic state. A prospective, single-blinded, randomized, crossover clinical trial investigating the safety and clinical efficacy of aDBS, the ADAPT-PD study, with the goal of future regulatory approval of this programming feature (NCT04547712) is underway. In the United States, FDA approval for the Percept™ RC IPG was obtained on 8 January 2024, and it is indicated for use in patients with PD, essential tremor, dystonia and epilepsy, but not obsessive-compulsive disorder. While the Percept™ RC neurostimulator incorporates many improvements, there are some key limitations that should be recognized. Future LFP-guided DBS programming innovations may require enhanced on-board computing power or software that will readily be addressed with the RC IPG. Deep brain stimulation (DBS) stands among other device-assisted therapies for the management of patients with advanced Parkinson’s disease (PD), and can lead to improved control of motor complications and refractory tremor while also reducing medications and improving quality of life. Neurophysiologic studies have identified that pathologic synchronization in beta frequency oscillations are consistently correlated to the hypodopaminergic state and akinetic-rigid symptoms in PD; these can be measured as local field potentials (LFPs) during brain recording and are also modulated by stimulation. The Percept™ RC neurostimulator is the first commercially available simultaneous sensing and stimulating device with rechargeability for PD and currently delivers open-loop, continuous stimulation like other platforms. BrainSense™ technology consists of five features including LFP survey, signal test, streaming, timeline and event recording, which can facilitate DBS programming by supporting contact selection, assessment of clinical response to stimulation, stimulation optimization and symptom characterization in PD. Motor symptoms, medication state, movement and location of the DBS lead can all affect LFP signals, particularly the beta frequency band, and these factors should be considered during interpretation and application of LFP analysis to DBS programming. Rechargeable neurostimulators confer advantages such as a smaller and thinner profile, more efficient charging, reduced need for battery replacements and prolonged therapy continuation. The Percept™ RC neurostimulator is conditionally compatible with both 1.5T and 3T MRI. However, strict adherence to MRI guidelines and workflow is required to ensure system integrity and patient safety. Closed loop stimulation (also called adaptive DBS) may mitigate some of the limitations of continuous DBS and provide more individualized treatment to patients with PD; early evidence supports its use in PD and uses BrainSense™ features enabled by the Percept™ RC neurostimulator.