Wednesday, September 21, 2022

Deep Brain Stimulation For Parkinson’s Disease Before And After

Conflict Of Interest Statement

Parkinson’s Disease Before and After Deep Brain Stimulation

PH is the director of the Duke University Parkinson Disease and Movement Disorders fellowship, which receives grant support from Medtronic. MS works for Duke University, and has received consultancy fees from Eli Lilly, Merz, Osmotica, Pfizer, SK Life Sciences, Allergan, Avid, Best Doctors, Biotie, Lundbeck, Neuronova, Novartis Pharma , Saraepta Therapeutics, and Sunovion Pharmaceutics, Inc. Dr. MS has also received grants from the Michael J. Fox Foundation, the NIH, the Parkinson Study Group, and Pharma 2B, royalties from Informa Press for the Handbook of Dystonia and Duke University for the Wearing Off Questionnaire. He has also received payment for development of educational presentations from the University of Kansas, the University of Miami, and the University of Rochester. Dr. MS also received paid travel accommodations from the Cleveland Clinic Neurological Institute, the Movement Disorder Society, and the National Parkinson Foundation.

Stereotactic Dbs Vs Interventional Image

Stereotactic DBS surgery requires the patient to be off their medication. During the procedure, a frame stabilizes the head and provides coordinates to help the surgeons guide the lead to the correct location in the brain. The patient gets local anesthesia to keep them comfortable throughout each step along with a mild sedative to help them relax.

During image-guided DBS surgery, such as with interventional MRI or CT scan, the patient is often asleep under general anesthesia while the surgeon uses images of the brain to guide the lead to its target.

Some advanced centers offer both the stereotactic and iMRI-guided options for DBS surgery. In this case, the doctor and patient will discuss which procedure is better based on a number of factors.

For instance, the doctor may recommend an image-guided procedure for children, patients who have extreme symptoms, those who are especially anxious or fearful or those whose leads are going into certain parts of the brain.

Generally, DBS surgery follows this process:

How Deep Brain Stimulation Works

Exactly how DBS works is not completely understood, but many experts believe it regulates abnormal electrical signaling patterns in the brain. To control normal movement and other functions, brain cells communicate with each other using electrical signals. In Parkinson’s disease, these signals become irregular and uncoordinated, which leads to motor symptoms. DBS may interrupt the irregular signaling patterns so cells can communicate more smoothly and symptoms lessen.

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Deep Brain Stimulation Surgery And Implantation

DBS consists of two surgeries, spaced approximately three to six weeks apart to ensure the patient has adequate time to recover. Throughout your experience, you will be attended to by a top team of physicians and other medical experts including a neurosurgeon, an electrophysiologist, and an anesthesiologist.

It should be noted that DBS offers many benefits. The generator can be programmed by a neurologist, and customized to each individual patient. The procedure is also reversible. Most patients experience a significant improvement of symptoms. However, as with any brain surgery, there are risks. With DBS, the risk of stroke is 1 in 100 and infection is 1 in 50.

Today, many more patients could be helped by DBS than are currently benefiting from the procedure. Statistics show only 7 percent of Parkinsons disease and 1 percent of tremor patients in Michigan who would benefit from the procedure have undergone DBS. At U-M, we are proud to have one of the superior DBS programs in the country. We have developed a wide array of ways to improve DBS, including special imaging tools that help doctors more accurately place the electrodes, and lead intraoperative motor and speech testing that result in fewer side effects for the patient.

U-M is also home to an active research program, where our team of experts is always working on ways to make DBS faster and more accurate. We also regularly have clinical trials available for patients interested in participating.

Preoperative Rem Sleep Behavior Disorder And Subthalamic Nucleus Deep Brain Stimulation Outcome In Parkinson Disease 1 Year After Surgerylearning Objectives:

Parkinson

Upon completion of the article by Besse-Pinot et al, the participant should be able to:

  • State differences in characteristics between preoperative patients with REM sleep behavior disorder and those without REM sleep behavior disorder in this study
  • Discuss differences between RBD+ and RBD patients in quality of life outcomes after surgery found in this study
  • Compare the motor outcome for RBD+ and RBD patients after surgery in this study

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Surgery To Implant The Deep Brain Stimulation Device

Deep brain stimulation requires the surgical implantation of an electrical device into the brain. A neurosurgeon uses imaging scans to pinpoint the right spot in the brain for implanting the electrode.

When surgeons have determined the correct location, they create a small opening in the skull and insert a thin, insulated wire, through which they insert the electrode. Surgery to implant the electrode takes about four hours and requires general anesthesia. You may then stay overnight in the hospital for observation.

The next day, doctors perform the second part of the surgery, which involves connecting the insulated wire to a battery-operated pulse generator that is implanted under the skin near the collarbone. Most people can return home after this procedure.

Several days after the surgery, you meet with your neurologist, who programs the pulse generator. Pushing a button on an external remote control sends electrical impulses from the pulse generator to the electrode in the brain.

People who use deep brain stimulation work closely with their neurologist to find the combination of settings that best controls their symptoms. After several visits, they are able to control the strength of the electrical impulses on their own. Following this adjustment period, most people require only occasional maintenance visits.

The Symptoms That Dbs Treats

Deep brain stimulation is used primarily to treat the motor symptoms of Parkinsons disease, but this can vary somewhat between the different placement sites. Symptoms treated include:

  • Stiffness
  • Abnormal movements : Dyskinesias are often a side effect of medications for Parkinsons disease and include involuntary movements such as twisting, head bobbing, squirming, and more.

DBS is not usually helpful with walking problems or balance, though improvements in the symptoms above can indirectly affect walking. It also does not provide significant benefits for non-motor symptoms of Parkinsons such as cognitive changes, mood changes , or problems with sleeping.

The benefits of DBS can be estimated by looking at how a person responds to levodopa. Symptoms that respond to levodopa will often respond to DBS . But symptoms that are not changed with levodopa are unlikely to be improved by DBS.

DBS often allows for a reduction in the dosage of levodopa, which in turn can result in fewer involuntary movements and a reduction in off time. The result is often improved quality of life.

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Life After Dbs Surgery

Once the neurotransmitter has been programmed, you are given a handheld controller to make adjustments.

With the controller, you can turn the simulator on or off, select the signal strength, and move across different program types.

If your DBS neurotransmitter has a rechargeable battery, then it will take about two hours for the device to recharge completely.

Make sure to carry your Implanted Device Identification card if you are traveling by air, as Airport Security will detect the device.

Who Is A Candidate For Deep Brain Stimulation

Deep Brain Stimulation for Parkinson’s (Before and After Surgery)

DBS is more than just a surgical procedure. It involves a series of evaluations, procedures, and consultations before and after the actual operation, so people interested in being treated with DBS should be prepared to commit time to the process.

For example, those who do not live close to a medical center that offers DBS surgery may need to spend significant time traveling back and forth to appointments.

The procedure, as well as the pre-operative evaluation and post-operative follow-up, can be expensive depending on the persons insurance coverage. DBS surgery is an FDA-approved treatment for Parkinsons disease, and Medicare and most private insurers cover the procedure, but the extent of coverage will depend on each persons individual policy.

Prospective patients should have realistic expectations about DBS results. Although DBS can improve movement symptoms of Parkinsons disease and greatly improve quality of life in properly selected patients, it is not likely to return anyone to perfect health.

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Will I Be Asleep During The Entire Procedure

You will be sedated or receive local anesthesia for part of the procedure, may or may not be awake for lead and electrode placement, and will be asleep when the impulse generator is implanted. To provide more details:

  • A local anesthetic is applied to areas of the head where pins or screws are used to secure the head frame and sedation is given.
  • You will be sedated during the beginning of the procedure, while the surgical team is opening the skin and drilling the opening in the skull for placement of the lead.
  • Most patients will be awake for lead and electrode placement. This part of the procedure is not painful, as the brain does not feel pain. Being awake allows the surgical team to interact with you when testing the effects of the stimulation. However, some patients who cannot tolerate the procedure while awake can have the electrode and lead placed under general anesthesia. The lead placement is guided in real time by magnetic resonance imaging. The procedure is performed in a special MR-equipped operation room.
  • Implantation of the pulse generator in the chest and connection of the leads from the device to the lead in the brain is usually done under general anesthesia.

What Happens After Surgery

After surgery, you may take your regular dose of Parkinson’s medication immediately. You are kept overnight for monitoring and observation. Most patients are discharged home the next day.

During the recovery time after implanting the electrodes, you may feel better than normal. Brain swelling around the electrode tip causes a lesion effect that lasts a couple days to weeks. This temporary effect is a good predictor of your outcome once the stimulator is implanted and programmed.

About a week later, you will return to the hospital for outpatient surgery to implant the stimulator in the chest/abdomen. This surgery is performed under general anesthesia and takes about an hour. Patients go home the same day.

Step 7: implant the stimulator You will be taken to the OR and put to sleep with general anesthesia. A portion of the scalp incision is reopened to access the leads. A small incision is made near the collarbone and the neurostimulator is implanted under the skin. The lead is attached to an extension wire that is passed under the skin of the scalp, down the neck, to the stimulator/battery in the chest or abdomen. The device will be visible as a small bulge under the skin, but it is usually not seen under clothes.

You should avoid arm movements over your shoulder and excessive stretching of your neck while the incisions heal. Pain at the incision sites can be managed with medication.

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Historical Perspective Of Deep Brain Stimulation

Parkinson

Prior to the discovery of levodopa, surgical interventions were the most efficacious treatment for PD symptoms, but primarily focused on the reduction of bothersome tremor. Early approaches targeted the pyramidal tracts, with lesioning either at the point of origin in the cortex or the descending pathways through the brainstem and cervical spinal cord . Although tremor was reliably improved following surgery, hemiparesis was an inevitable consequence. However, in 1952, Dr. Irving Cooper inadvertently interrupted the anterior choroidal artery while performing a mesencephalic pedunculotomy in a patient with PD. Ligation of the vessel was required, though what resulted was a serendipitous reduction in rigidity and tremor with preservation of motor and sensory function. Cooper reasoned the favorable outcomes were due to infarction of the medial globus pallidus. An expansion of ablative stereotactic surgery followed, aided by the earlier development of the stereotactic frame and methods of targeting deep brain structures, including the basal ganglia and thalamus. However, the success of these approaches was limited, partly because of inaccurate, imprecise, and inconsistent targeting. Moreover, intentionally created bilateral brain lesions frequently led to irreversible deficits in speech, swallowing, and cognition.

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What Benefits Does The Procedure Offer

DBS is not a cure for Parkinsons, but it may help control motor symptoms while allowing a reduction in levodopa dose. This can help reduce dyskinesias and reduce off time. DBS does not usually increase the peak benefits derived from a dose of levodopa the best levodopa response before DBS is a good indicator of the best response after DBS. But it can help extend the amount of on time without dyskinesias, which may significantly increase quality of life.

DBS does not provide most patients benefit for their non-motor symptoms, such as depression, sleep disturbance, or anxiety. DBS also does not usually improve postural instability or walking problems. If a symptom you have does not respond to levodopa, it is not likely to respond to DBS.

What It Feels Like: Deep Brain Stimulation For Parkinson’s Disease

Emma Jones,

Manzil Bacchus was diagnosed with Parkinsons disease in 2008. Initially, he was told that there was nothing he could do to stop the progression of the progressive nervous system disorder that affects movement. Manzil and his wife, Sadia, continued to manage the increasingly worrisome symptoms which included tremors and the growing amount of medication that he had to take each day.

After Manzil was diagnosed with colitis, a chronic digestive disease that has been linked to Parkinsons, the family began investigating a new surgical option. In deep brain stimulation , electrodes are inserted in regions of the brain that have been affected by the Parkinsons, with an impulse generator battery also inserted in another area of the body. When turned on, the electrodes send gentle electrical pulses to help improve symptoms like tremors and motor control.

Manzil and Sadia sat down with Healthing to talk about Manzils experience having brain surgery during the COVID-19 pandemic and the difference that deep brain stimulation has made to his quality of life.

When was Manzil diagnosed with Parkinsons?Manzil: Back in 2007, my hands started shaking. I was volunteering at a mosque, helping people to take a pilgrimage in Saudi Arabia, helping with their application for visas and stuff like that. One of the girls noticed my hand shaking and asked why. I thought I was just tired. After that, I also noticed that my left foot was dragging when I walked.

Sadia: Sadia: Sadia:

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Depression And Parkinson’s Disease

Depression in PD is a common finding, and has an important impact on patient’s quality of life . Published prevalence estimates vary depending on the population studied, but significant depressive symptoms occur in around 35% of patients . The impact of depression on patients’ well-being can hardly be overestimated. It appears to be more distressing for patients and their families than motor symptoms . Treating depression have beneficial effects also on motor performance and conversely depressive symptoms are among the stronger predictors of initiation of dopaminergic therapy .

Who Is A Candidate

Parkinson’s Disease before/after Deep Brain Stimulation

You may be a candidate for DBS if you have:

  • a movement disorder with worsening symptoms and your medications have begun to lose effectiveness.
  • troubling “off” periods when your medication wears off before the next dose can be taken.
  • troubling “on” periods when you develop medication-induced dyskinesias .

DBS may not be an option if you have severe untreated depression, advanced dementia, or if you have symptoms that are not typical for Parkinson’s.

DBS can help treat many of the symptoms caused by:

  • Parkinson’s disease: tremor, rigidity, and slowness of movement caused by the death of dopamine-producing nerve cells responsible for relaying messages that control body movement.
  • Essential tremor: involuntary rhythmic tremors of the hands and arms, occurring both at rest and during purposeful movement. Also may affect the head in a “no-no” motion.
  • Dystonia: involuntary movements and prolonged muscle contraction, resulting in twisting or writhing body motions, tremor, and abnormal posture. May involve the entire body, or only an isolated area. Spasms can often be suppressed by “sensory tricks,” such as touching the face, eyebrows, or hands.

After your evaluation and videotaping is complete, your case will be discussed at a conference with multiple physicians, nurses, and surgeons. The team discusses the best treatment plan for each patient. If the team agrees that you are a good candidate for DBS, you will be contacted to schedule an appointment with a neurosurgeon.

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Awake Vs Asleep Surgery

Standard DBS surgery is performed while you are awake and requires that you stop taking the medicines that control your Parkinson’s symptoms. During surgery, you are asked to perform tasks to help guide the electrode to the precise location in the brain.

Being awake during brain surgery, or being off medicine, is unsettling for some people. Asleep DBS is an alternative option at some centers.

Asleep DBS surgery is performed while you are unconscious and under anesthesia. Surgery takes place in an MRI or CT scanner to target and verify accurate placement of your DBS electrodes. Ask your surgeon if asleep DBS is an option for you.

Must hold medications the morning of surgery Don’t have to hold medications

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