Evolution and resolution of stimulation-induced axonal injury in peripheral nerve.

We describe the evolution of axonal injury following the induction of neural damage by electrical stimulation. The sciatic nerves of cats were stimulated continuously for 8 h with charge-balanced waveforms at high intensities, 50 Hz and 2100-4500 microA, using circumneural helical electrodes. Computer-assisted morphometric and ultrastructural studies indicate that many of the damaged fibers had not regenerated by 125 days after stimulation. Functional deficits were not observed in any of the animals, and most of the fibers appeared to be histologically normal at 125 days after stimulation. These findings indicate that there is relatively little late-onset injury associated with the stimulation. However, the slow, and possibly incomplete, recovery of the damaged axons emphasizes the importance of using stimulus protocols with adequate margins of safety.

Stability of the interface between neural tissue and chronically implanted intracortical microelectrodes.

The stability of the interface between neural tissue and chronically implanted microelectrodes is very important for obtaining reliable control signals for neuroprosthetic devices. Stability is also crucial for chronic microstimulation of the cerebral cortex. However, changes of the electrode-tissue interface can be caused by a variety of mechanisms. In the present study, intracortical microelectrode arrays were implanted into the pericruciate gyrus of cats and neural activities were recorded on a regular basis for several months. An algorithm based on cluster analysis and interspike interval analysis was developed to sort the extracellular action potentials into single units. We tracked these units based on their waveform and their response to somatic stimulation or stereotypical movements by the cats. Our results indicate that, after implantation, the electrode-tissue interface may change from day-to-day over the first 1-2 weeks, week-to-week for 1-2 months, and become quite stable thereafter. A stability index is proposed to quantify the stability of the electrode-tissue interface. The reasons for the pattern of changes are discussed.

A characterization of the effects on neuronal excitability due to prolonged microstimulation with chronically implanted microelectrodes.

Localized, long-lasting stimulation-induced depression of neuronal excitability (SIDNE) is a consequence of prolonged, high-frequency microstimulation in the central nervous system (CNS). It represents a persisting refractory state in the neurons and axons near the stimulating microelectrode, that occurs in the absence of histologically detectable tissue injury. It does not involve a change in synaptic efficacy and, in this respect, it differs from the more familiar phenomenon of long-term depression (LTD). Although SIDNE is ultimately reversible (after several days), it must be taken into account in the design of neural prostheses based on microstimulation in the central nervous system and in animal studies that require prolonged microstimulation in the CNS. In this study, we have characterized the phenomenon, using as the paradigm, iridium microelectrodes implanted chronically in the cat's posteroventral cochlear nucleus. Although the SIDNE may persist for several days after the end of the stimulation protocol, it does not become more severe from day to day when the stimulation protocol is repeated on successive days. The severity of the SIDNE is strongly dependent upon both the instantaneous frequency and the duty cycle of the electrical stimulation. The character of the SIDNE, including its localization to the immediate vicinity of the stimulating microelectrodes, suggests that the phenomenon is a direct consequence of the prolonged electrical excitation of the neurons close to the microelectrode. The problem of designing microstimulation systems that allow high-frequency stimulation of a neural substrate, while minimizing SIDNE are discussed.

A quantitative computer-assisted morphometric analysis of stimulation-induced injury to myelinated fibers in a peripheral nerve.

We describe a computer-assisted morphometric procedure for quantifying acute axonal injury induced in peripheral nerves by prolonged electrical stimulation. The procedure is a two-phase process, with the image analysis implemented via a commercial image analysis program, followed by an automated editing of the morphometric parameters of each object identified by the image analysis software. Both phases are implemented on IBM-compatible personal computers. The custom software counts the number of fibers undergoing early axonal degeneration, using a two-category classification scheme based on the range of myelin cross-sectional area and axonal cross-sectional areas of normal (unstimulated) nerves. When the damaged fibers are counted using this procedure, the correlation between the normalized amplitude of the electric stimulus and the number of degenerating fibers is the same as when the analysis is performed by an experienced histopathologist (R = 0.87) and carries the advantage of being entirely objective. The correlation was higher with a two-category classification (damage/no damage) than when the severity of the damage to each axon was weighted according to the amount of axonal shrinkage. We determined that axons 3.5-9 microm in diameter are the most vulnerable to injury from the electrical stimulation. This has certain implications regarding the mechanism underlying this type of injury.

Histopathologic and physiologic effects of chronic implantation of microelectrodes in sacral spinal cord of the cat.

Active microelectrodes were implanted for a period of 2 weeks to 3 months into the sacral spinal cord of 10 male cats in order to test the feasibility and the safety of discrete stimulation of the parasympathetic preganglionic nucleus for future clinical applications of microelectrode technology in micturition control. An array of four 50 microns-diameter iridium microelectrodes was inserted beneath the dura in each cat. At weekly intervals, bladder pressure was measured as hydrostatic pressure on an intraluminal catheter. At the end of the period, histopathology was evaluated with serial transverse epoxy sections. Observations included diffuse and focal axonal degeneration in white matter and possible neuronal loss around the electrode in the gray matter, meningeal ensheathment of the shafts, and occasional aseptic inflammation of tissue and apparent movement of the electrodes after implantation. Increased bladder pressure responses to individually pulsed electrodes located within the sacral parasympathetic nucleus were not consistent, and, surprisingly, at least 2 different sites were also effective. As long as 3 months after implantation, in 2 out of 5 animals, pulsing of electrodes consistently produced micturition. We conclude that while microelectrode implants are feasible, further modifications in electrode design are needed to eliminate movement and inflammation.

Histological evaluation of polyesterimide-insulated gold wires in brain.

Polyesterimide-coated gold wires were implanted subdurally on the parietal cortex of rabbits for 16 weeks. Light microscope examination of the implant sites showed no evidence of toxicity. There was no inflammatory response of the adjacent parenchyma. Gliosis in the molecular or neuronal layers was only slight to moderate. Overall, the polymer demonstrated good biocompatibility at 16 weeks after implantation. Future, long-term biocompatibility studies of this material are indicated, including evaluation of tumourigenic properties.

Relationship between stimulus amplitude, stimulus frequency and neural damage during electrical stimulation of sciatic nerve of cat.

The relation is investigated between stimulus frequency, stimulus pulse amplitude and the neural damage induced by continuous stimulation of the cat's sciatic nerve. The chronically implanted electrodes were pulsed continuously and the effects of the electrical stimulation were quantified as the amount of early axonal degeneration (EAD) present in the nerves seven days after the continuous stimulation. The primary effect of stimulating at 100 Hz rather than 50 Hz was to cause an increase in the slope of the plot of the amount of EAD versus stimulus amplitude, but the threshold stimulus for the induction of EAD also was slightly lower. There was a small amount of EAD in three of the nerves stimulated at 20 Hz, but there was no detectable correlation between the amount of EAD and the stimulus amplitude. This suggests that continuous electrical stimulation of peripheral nerves at a low frequency induce little or no neural damage, even if the stimulus amplitude is very high. A preliminary presentation of the results has been made elsewhere (Agnew et al., 1993).

Stimulus parameters affecting tissue injury during microstimulation in the cochlear nucleus of the cat.

We investigated the effects of continuous microstimulation in the cats' posteroventral cochlear nucleus, using chronically implanted activated iridium microelectrodes. We examined 51 electrode sites (39 pulsed sites, and 12 unpulsed sites). Seven hours of continuous stimulation at 500 Hz often produced tissue injury near the tips of the pulsed microelectrodes. The damage took the form of a region of vacuolated tissue extending 200 microns or more from the site of the electrode tip. Electron microscope studies showed the vacuoles to be severely edematous segments of myelinated axons. The statistical correlation between the amount of damaged tissue and the charge per phase was large and highly significant (P < 0.0001). When the electrodes were pulsed for 7 h at 500 Hz with charge-balanced biphasic pulse pairs, the threshold for the damage was approximately 3 nC/phase. The damage threshold was not appreciably lower than the stimulation protocol was extended to 35 h (7 h/day for 5 days). In contrast, the threshold for exciting neurons near the microelectrode is approximately 1 nC/phase, as determined by the evoked response recorded in the inferior colliculus. There was little correlation between the severity of the tissue damage and the geometric charge density at the surface of the electrodes, between the damage and amplitude of the cathodic phase of the voltage transient induced across the stimulating electrodes by the stimulus current pulses, or between the damage and the stimulus pulse duration.

MK-801 protects against neuronal injury induced by electrical stimulation.

The ability of MK-801, a non-competitive N-methyl-D-aspartate receptor antagonist, to protect neurons in the cerebral cortex from injury induced by prolonged electrical stimulation was assessed in cats. Platinum disc electrodes 8.0 mm in diameter and with a surface area of 0.5 cm2 were implanted in the subdural space over the parietal cortex. Ten days after implantation of the electrodes, all animals received continuous stimulation for 7 h using charge-balanced, cathodic-first, controlled current pulses with a charge density of 20 microC/cm2 and a charge/phase of 10 microC/phase. They received either no MK-801, or 0.33 or 5.0 mg/kg (i.v.) administered intravenously, just before the start of the stimulation. Immediately following the stimulation, the animals were perfused and the cerebral cortex examined by light microscopy at eight sites beneath the electrodes. Neuronal damage in the form of shrunken, hyperchromic neurons and perineuronal halos was present only beneath the stimulating electrodes; damage was moderate to severe in stimulated animals that had not received MK-801, slight in animals receiving 0.33 mg/kg, and none to slight in animals receiving 5.0 mg/kg. These results indicate that MK-801, in an apparently dose-dependent fashion, provides substantial but not complete protection against neuronal injury induced by prolonged electrical stimulation. Thus prolonged electrical stimulation can be added to the list of neuropathologic conditions which involve glutamate-induced excitotoxic damage via the N-methyl-D-aspartate receptor. The results also support the hypothesis of neuronal hyperactivity as a principal cause of electrically-induced injury in the central nervous system. The implications for design of protocols for functional electrical stimulation are discussed.

Stimulation with chronically implanted microelectrodes in the cochlear nucleus of the cat: histologic and physiologic effects.

The effects of several hours of continuous electrical stimulation in the cats' cochlear nucleus with chronically implanted activated iridium microelectrodes was investigated from the changes in the evoked response near the inferior colliculus and also by histologic evaluation of the stimulated tissue. The stimulating microelectrodes had geometric surface areas of 75-500 microns2. They were pulsed continuously for 4 h, at a pulse repetition rate of 200 Hz, using charge-balanced pulse pairs. The charge per phase was 1.8 or 3.6 nC/ph. The animals were sacrificed for histologic evaluation 2 h, or several days later. The only remarkable histologic change resulting from the 4 h of stimulation was some aggregation of lymphocytes at the site of stimulation. However, depression of the electrical excitability of neurons near the sites often persisted for several days after 4 h of stimulation at 3.6 nC/phase. The charge per phase of the stimulus pulse pair was correlated strongly with the depression of excitability, and there was a weaker correlation between the depression and the amplitude of the first phase of voltage transient induced across the electrode-tissue interface. The charge density, calculated from the geometric surface area of the stimulating electrodes, was poorly correlated with the severity of the depression. The findings suggest a means of detecting impending stimulation-induced neural damage while it is still reversible.

Damage in peripheral nerve from continuous electrical stimulation: comparison of two stimulus waveforms.

The propensity for two types of charge-balanced stimulus waveforms to induce injury during eight hours of continuous electrical stimulation of the cat sciatic nerve was investigated. One waveform was a biphasic, controlled-current pulse pair, each phase 50 microseconds in duration, with no delay between the phases ('short pulse', selected to excite primarily large axons), whereas in the second type each phase was 100 microseconds in duration, with a 400 microsecond delay between the phases (selected to excite axons of a broader spectrum of diameters). The sciatic nerve was examined for early axonal degeneration (EAD) seven days after the session of continuous stimulation. With both waveforms, the threshold stimulus current for axonal injury was greater than the current required to excite all of the nerve's large axons. The correlation between simple stimulus parameters and the amount of EAD was poor, especially with the 'short pulse' waveform, probably due to variability between animals. When the stimulus was normalised with respect to the current required to fully recruit the large axons, a good association between damage and stimulus amplitude emerged. The damage threshold was higher for the 'short pulse' waveform. The implications for clinical protocols are discussed.

Charge density and charge per phase as cofactors in neural injury induced by electrical stimulation.

The possibility of neural injury during prolonged electrical stimulation of the brain imposes some constraints on the use of this technique for therapeutic and experimental applications. Stimulating electrodes of various sizes were used to investigate the interactions of two stimulus parameters, charge density and charge per phase, in determining the threshold of neural injury induced by electrical stimulation. Platinum electrodes ranging in size from 0.002 to 0.5 cm2 were implanted over the parietal cortex of adult cats. Penetrating microelectrodes fabricated from iridium, with surface areas of 65 +/- 3 x 10(-6) cm2 were inserted into the parietal cortex. Ten days after implantation, the electrodes were pulsed continuously for 7h using charge balanced, current regulated, symmetric pulse pairs, 400 microseconds per phase in duration, at a repetition rate of 50 Hz. The animals were perfused immediately after the stimulation for histologic evaluation of the brain tissue subjacent to the electrode sites. The results show that charge density (as measured at the surface of the stimulating electrode), and charge per phase, interact in a synergistic manner to determine the threshold of stimulation-induced neural injury. This interaction occurs over a wide range of both parameters; for charge density from at least 10 to 800 microC/cm2 and, for charge per phase, from at least 0.05 to 5.0 microC per phase. The significance of these findings in elucidating the mechanisms underlying stimulation-induced injury is discussed.

Local anaesthetic block protects against electrically-induced damage in peripheral nerve.

This study is one of a series addressing the mechanisms involved in the production of neural damage caused by continuous, prolonged electrical stimulation of peripheral nerve. It has been previously shown that sustained, high frequency electrical stimulation of the cat's peroneal nerve may cause irreversible neural damage in the form of axonal degeneration of the large myelinated fibres. In this study we demonstrate that blocking the action potentials on most of the nerve fibres with local anaesthetics (10% procaine or 2% lidocaine) almost completely prevents the axonal degeneration. The abolition of axonal injury by local anaesthetic block strongly suggests that the electrically-induced damage is due to prolonged electrical excitation of axons. Furthermore, since less than complete suppression of the induced neural activity by local anaesthetic engenders essentially complete sparing of all axons, our results suggest that the damage to individual axons derives, at least in part, from stimulation-induced global changes in the nerve.

Partial pressure of oxygen in brain and peripheral nerve during damaging electrical stimulation.

The studies were performed to elucidate the mechanism underlying the neural damage which may occur during prolonged electrical stimulation of either brain tissue or peripheral nerve. The partial pressure of oxygen (pO2) was measured in the sciatic nerve and the cerebral cortex of adult cats before and during direct, local electrical stimulation of these neural tissues, using stimulus parameters capable of inducing neural injury. pO2 was monitored by the polarographic method, employing a platinum microelectrode inserted into the tissue adjacent to or beneath the stimulating electrode. In the sciatic nerve there was no marked change in intrafascicular pO2 in three cats upon initiation of the electrical stimulation. In a fourth animal intraneural pO2 increased briefly upon initiation of the stimulation. In no case did the intrafascicular compartment of nerves become significantly hypoxic. In the cerebral cortex, the start of stimulation was accompanied by a significant increase (approximately 12-15 Torr) in intracortical pO2 beneath the stimulating electrode, and pO2 remained at or above the pre-stimulus value for the duration of the stimulation. These results show that extracellular hypoxia is unlikely to be a significant factor in the neural injury induced in brain or peripheral nerve by prolonged electrical stimulation.

Considerations for safety with chronically implanted nerve electrodes.

Electrical stimulation of cranial and peripheral nerves has been used to ameliorate a variety of neurologic disease states and neural injuries over the past 20 years. In this review, clinical applications and the histopathologic results of chronic implants in animals and humans are discussed, and the results of neural damage models developed at Huntington Medical Research Institutes are summarized. Chronically implanted electrode arrays may produce neural injury by either mechanical factors or by continuous, high-frequency electrical stimulation. The margin of safety to avoid electrically induced injury may be increased by minimizing the frequency or total stimulation time, and by the use of an intermittent duty cycle. The protocols presently being used for the stimulation of the vagus nerve to effect inhibition of seizures appear to have an adequate margin of safety.

Histologic and physiologic evaluation of electrically stimulated peripheral nerve: considerations for the selection of parameters.

Helical electrodes were implanted around the left and right common peroneal nerves of cats. Three weeks after implantation one nerve was stimulated for 4-16 hours using charge-balanced, biphasic, constant current pulses. Compound action potentials (CAP) evoked by the stimulus were recorded from over the cauda equina before, during and after the stimulation. Light and electron microscopy evaluations were conducted at various times following the stimulation. The mere presence of the electrode invariably resulted in thickened epineurium and in some cases increased peripheral endoneurial connective tissue beneath the electrodes. Physiologic changes during stimulation included elevation of the electrical threshold of the large axons in the nerve. This was reversed within one week after stimulation at a frequency of 20 Hz, but often was not reversed following stimulation at 50-100 Hz. Continuous stimulation at 50 Hz for 8-16 hours at 400 microA or more resulted in neural damage characterized by endoneurial edema beginning within 48 hours after stimulation, and early axonal degeneration (EAD) of the large myelinated fibers, beginning by 1 week after stimulation. Neural damage due to electrical stimulation was decreased or abolished by reduction of the duration of stimulation, by stimulating at 20 Hz (vs. 50 Hz) or by use of an intermittent duty cycle. These results demonstrate that axons in peripheral nerves can be irreversely damaged by 8-16 hours of continuous stimulation at 50 Hz. However, the extent to which these axons may subsequently regenerate is uncertain. Therefore, protocols for functional electrical stimulation in human patients probably should be evaluated individually in animal studies.

Comparison of neural damage induced by electrical stimulation with faradaic and capacitor electrodes.

Arrays of platinum (faradaic) and anodized, sintered tantalum pentoxide (capacitor) electrodes were implanted bilaterally in the subdural space of the parietal cortex of the cat. Two weeks after implantation both types of electrodes were pulsed for seven hours with identical waveforms consisting of controlled-current, charge-balanced, symmetric, anodic-first pulse pairs, 400 microseconds/phase and a charge density of 80-100 microC/cm2 (microcoulombs per square cm) at 50 pps (pulses per second). One group of animals was sacrificed immediately following stimulation and a second smaller group one week after stimulation. Tissues beneath both types of pulsed electrodes were damaged, but the difference in damage for the two electrode types was not statistically significant. Tissue beneath unpulsed electrodes was normal. At the ultrastructural level, in animals killed immediately after stimulation, shrunken and hyperchromic neurons were intermixed with neurons showing early intracellular edema. Glial cells appeared essentially normal. In animals killed one week after stimulation most of the damaged neurons had recovered, but the presence of shrunken, vacuolated and degenerating neurons showed that some of the cells were damaged irreversibly. It is concluded that most of the neural damage from stimulations of the brain surface at the level used in this study derives from processes associated with passage of the stimulus current through tissue, such as neuronal hyperactivity rather than electrochemical reactions associated with current injection across the electrode-tissue interface, since such reactions occur only with the faradaic electrodes.

Characterization of electrode dissolution products on the high-voltage electron microscope.

Deposits left by electrodes and biocompatibility test specimens implanted in brain or peripheral nerve were characterized by X-ray microprobe analysis, electron diffraction and stereoscopic imaging using a high-voltage electron microscope. Examination of thick (1-micron) sections of neural tissue confirmed that the electron-dense bodies found adjacent to electrode positions consist of elements originating in the implant material (with the exceptions of the S and Se found in association with Ag). These elements have no long-range order, suggesting they are complexed with biological molecules. In some cases the deposits appear to be caused by pulsing the electrode with current, while in other cases the deposits are corroded or abraded from the electrode or are otherwise not associated with the neuroprosthetic functioning of the implant.

Tissue response to potential neuroprosthetic materials implanted subdurally.

A histologic study was made of the response of the leptomeninges and underlying cerebral cortex of the cat to subdural implantation of 3 insulating materials (HR605-P, Parylene-C and PI-2555) and a polymeric electrode component (MMA/MAPTAC) for periods of 8 and 16 wk. The tissue reactions were compared with those elicited by the arrays of Dacron mesh matrices, pure platinum controls and by positive controls (Ag-AgCl) known to cause reactions in the brain. Sites beneath the Dacron mesh matrix, pure platinum control implants and beneath all insulating materials implanted for 8 and 16 wk appeared indistinguishable, exhibiting little tissue reaction. All neurons appeared normal. The leptomeninges and cortex beneath the Ag-AgCl implants showed a chronic inflammatory reaction after 8 and 16 wk. Despite varying amounts of oedema, gliosis and ingrowth of connective tissue in the molecular layer, virtually all underlying neurons appeared normal.