His Right Leg Became Less Dyskinetic
Another positive change that Dad experienced after DBS was less overall dyskinesia, and especially in his right leg: When I used to come off of levodopa, my right leg would shake uncontrollably for 10 to 15 minutes, and thats gone away, he said. DBS totally took dyskinesia out of my right leg.
Since dyskinesia was one of the main reasons Dad decided to undergo DBS, I was happy to learn that it tackled some of his worst symptoms.
While Dad was initially worried about the potential negative side effects of undergoing DBS, hes a believer in the procedure now. I think the DBS works, and it continues, he said. It improves a little at a time. Its been four years, and it still functions quite well.
As for what Ive witnessed, I think Dad is experiencing a slower progression than he was before DBS. And for that, Ill be eternally grateful to his surgeon.
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Testing Before Deep Brain Stimulation
For patients with Parkinsons disease, the doctor must confirm that the PD is levodopa-responsive and determine which symptoms are most likely to respond to DBS and discuss these with the patient.
To accomplish these two objectives, the movement disorders neurologist will examine the patient in the absence of his or her PD medications, then again after having taken them. Seeing the effect of PD medications on the movement and non-motor symptoms helps the physician and patient identify good target symptoms for DBS.
A cognitive assessment can help determine a persons ability to participate in the procedure, which involves providing feedback to the doctor during surgery and throughout the neurostimulator adjustment process. This assessment also informs the team of the risk of having worsened confusion or cognitive problems following the procedure.
Some hospitals also perform an occupational therapy review or speech, language and swallowing assessment. A psychiatrist may examine the person to determine if a condition such as depression or anxiety requires treatment before the DBS procedure.
Role Of The Funding Source
The sponsor and the participating centres designed and approved the protocol. Medtronic monitored the study and the data were entered into a validated database. A statistician employed by the company performed the statistical analysis based on specific requests of the investigators. Final data were made available to the authors who independent of the sponsor assessed the data analysis as well as the interpretation and writing of the results.
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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.
What Are The Advantages Of Deep Brain Stimulation
DBS has several advantages. These include:
- It can offer a treatment option when medications arent helpful: DBS is an option when medications don’t work or are no longer effective. With Parkinsons disease, medications lose effectiveness over time, so your healthcare provider has to increase your dosage. That leads to other side effects. With DBS, lower medication dosages are often effective again, which means your symptoms are under control with reduced side effects.
- It can be a life-changing treatment: Some of the conditions that DBS treats can cause severe effects that keep you from doing even the most routine activities. DBS can treat your condition and improve your symptoms, improving your overall quality of life. For conditions like medication-resistant epilepsy, where surgical resection isn’t an option, DBS can offer hope and reduction in seizure frequency.
- Its adjustable: Your healthcare provider can fine-tune the pulse generator settings to find what works best for you.
- Its reversible: A follow-up surgery can remove the leads and pulse generator if DBS doesn’t work or causes side effects that you can’t tolerate.
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Benefits Of Deep Brain Stimulation
Generally, the benefit of deep brain stimulation is a reduction in seizure activity and an overall improvement in quality of life.
One report revealed around 69% of people who used DBS for epilepsy noticed a decrease in seizure activity five or more years after implantation of the stimulation device. About 6% said seizures had stopped entirely after DBS treatment.
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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Key Publications Of Alim Louis Benabid
Benabid, A.L., Pollak, P., Louveau, A., Henry, S., and de Rougemont, J. . Combined stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease. Appl. Neurophysiol. 50, 344-346.
Benabid, A.L., Pollak, P., Gervason, C., Hoffmann, D., Gao, D., Hommel, M., Perret, J.E., and de Rougemont, J. . Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet. 337, 403-406.
Limousin, P., Pollak, P., Benazzouz, A., Hoffmann, D., Le Bas, J.F., Broussole, E., Perret, J.E., and Benabid, A.L. . Effect on parkinsonian signs and symptoms of bilateral subthalamic nucleus stimulation. Lancet. 345, 91-95.
Limousin, P., Krack, P., Pollak, P., Benazzouz, A., Ardouin, C., Hoffmann, D., and Benabid, A.L. . Electrical stimulation of the subthalamic nucleus in advanced Parkinsons disease. N. Engl. J. Med. 339, 1105-1111.
Krack, P., Batir, A., Van Blercom, N., Chabardes, S., Fraix, V., Ardouin, C., Koudsie, A., Dowsey-Limousin, P., Benazzouz, A., Le Bas, J.F., Benabid, A.L., and Pollak, P. . Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinsons disease. N. Engl. J. Med. 349, 1925-1934.
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What Are The Results
Successful DBS is related to 1) appropriate patient selection, 2) appropriate selection of the brain area for stimulation, 3) precise positioning of the electrode during surgery, and 4) experienced programming and medication management.
For Parkinson’s disease, DBS of the subthalamic nucleus improves the symptoms of slowness, tremor, and rigidity in about 70% of patients . Most people are able to reduce their medications and lessen their side effects, including dyskinesias. It has also been shown to be superior in long term management of symptoms than medications .
For essential tremor, DBS of the thalamus may significantly reduce hand tremor in 60 to 90% of patients and may improve head and voice tremor.
DBS of the globus pallidus is most useful in treatment of dyskinesias , dystonias, as well as other tremors. For dystonia, DBS of the GPi may be the only effective treatment for debilitating symptoms. Though recent studies show little difference between GPi-DBS and STN-DBS.
Patients report other benefits of DBS. For example, better sleep, more involvement in physical activity, and improved quality of life .
Research suggests that DBS may “protect” or slow the Parkinson’s disease process .
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Coordinates Of Active Electrode Contacts
Retrospective analysis of the stereotactic position of the active electrode contacts was done in 25 patients for whom postoperative T1 weighted MRI of sufficient quality or stereotactic radiographic examinations were available. Such analyses could not be undertaken in other patients implanted with subthalamic nucleus electrodes during the same period because of motion artefacts in the postoperative MRI, missing postoperative T1 weighted MRI, or missing postoperative stereotactic x rays. For the 25 patients evaluated, the mean and median coordinates of all active contacts are summarised in table 3. The mean laterality of all active electrode contacts mm median 12.7 mm) correlated well with the laterality of the subthalamic nucleus, as determined 3 mm ventral to the intercommissural plane in T2 weighted MRI of 35 patients mm). However, in the dorso-ventral direction the mean and median z coordinate of all active contacts do not project within the subthalamic nucleus proper, but suggest an area between the dorsal margin of the subthalamic nucleus and the subthalamic region according to different stereotactic brain atlases. Moreover, 12 of 49 active contacts were located within 0.5 mm of the intercommissural plane or further dorsal they were thus most probably in the subthalamic area.
Active electrode contacts relative to the mid-commissural point
Which Brain Targets Should Be Used To Implant The Dbs Lead
- There are three brain targets that the FDA has approved for use in Parkinsons: the subthalamic nucleus and the globus pallidus interna are the most common.
- The target choice should be tailored to a persons individual needs.
- There are many ongoing studies that will help refine target choice for individual people.
- Although the picture is not yet clear on the issue of target choice, the STN seems to provide more medication reduction, while GPi may be slightly safer for language and cognition.
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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.
What Happens Before Surgery
In the doctor’s office you will sign consent forms and complete paperwork to inform the surgeon about your medical history, including allergies, medicines, anesthesia reactions, and previous surgeries. Presurgical tests may need to be done several days before surgery. Consult your primary care physician about stopping certain medications and ensure you are cleared for surgery.You may also need clearance from your cardiologist if you have a history of heart conditions.
Stop taking all non-steroidal anti-inflammatory medicines and blood thinners 7 days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems.
You may be asked to wash your skin and hair with Hibiclens or Dial soap before surgery. It kills bacteria and reduces surgical site infections.
No food or drink, including your Parkinson’s medication, is permitted after midnight the night before surgery.
Try to get a good night’s sleep. The DBS surgery involves multiple steps and lasts most of the day, during which you may be awake and off medication.
Morning of surgery
Arrive at the hospital 2 hours before your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks.
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Pallidal Stimulation Versus Subthalamic Stimulation
As mentioned, there are two main anatomic targets for using DBS to treat PD the STN and the GPi. There have been several large randomized studies comparing STN and GPi DBS in PD. It is suggested that both STN DBS and GPi DBS overall equally and successfully improve motor symptom, and are similar in cost-effectiveness. However, although no differences were observed in the on phase between STN DBS and GPi DBS, significant differences were seen in the off phase STN DBS was more effective in terms of motor function improvement in the off phase. There are different opinions in terms of effects of STN DBS and GPi DBS on quality of life. Some authors have found no significant difference between the STN and GPi targets. However, others agree with that greater improvements in quality-of-life measures are achieved in patients with GPi DBS.
GPi DBS can be used for patients with more axial symptoms, gait issues, dyskinesias, depression, and word fluency problems. STN DBS is often favored in reducing medication post surgery, and for patients with greater tremor. STN-DBS has also demonstrated an improvement in the quality of sleep for patients.
How Effective Is It
DBS does not cure or slow the progression of Parkinsons disease. However, many people report that it helps them control the motor symptoms of the condition.
The Parkinsons Foundation says that DBS improves symptoms in many people. However, it is different for everyone.
Some people experience a mild improvement, while others experience a significant improvement. Some people may be able to stop taking their Parkinsons disease medication, while others will not.
DBS is not the right treatment choice for everyone. Doctors tend to only recommend it in advanced Parkinsons disease and when more standard medications are not working as well as they should.
According to the Parkinsons Foundation, people who are best suited to DBS:
- have had Parkinsons disease symptoms for at least 5 years
- experience on/off fluctuations in symptoms, even though they are taking medications
- have dyskinesia
There are three components of the DBS system:
- The lead: This is also called an electrode. It is a thin, insulated wire.
- The extension: This is another insulated wire that connects the lead to the neurostimulator.
- The neurostimulator, or IPG: This is essentially the battery pack.
According to Johns Hopkins, during the procedure, a surgeon will implant the three pieces of the DBS system into the persons body.
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How Does It Work
A small device placed inside your chest sends electrical pulses to your brain. The pulses block nerve signals that cause Parkinson’s symptoms.
A DBS system has four parts:
- A thin wire, called a lead, that’s placed in the part of your brain causing symptoms
- A pulse generator, like a pacemaker, that sends tiny electrical signals to the lead
- A wire that connects the lead to the pulse generator
- A remote control to program the system — the only part outside your body
After the system is in place and turned on, a DBS expert will adjust it so you get the best relief for your symptoms.
You can also control the system yourself. You can turn it off and on, check the battery, and tweak the settings.
What Risks Come Along With Doing Deep Brain Stimulation
DBS is a surgical procedure. As with any surgery there are some risks associated with it. Some of the risks of DBS include infection and bleeding. Your neurosurgeon may discuss some additional risks with you. Studies have shown that any risks are relatively small, but they should be kept in mind when considering DBS.
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Mechanism Of Action Of Dbs
Current hypotheses on the action mechanism of DBS include depolarization blockade , synaptic inhibition , synaptic depression , stimulation-induced disruption of pathological network activity , and stimulation of afferent axons projecting to the STN . Depolarization blockade and synaptic inhibition are likely to explain the similarity between the therapeutic benefit of DBS and lesional surgery. Recordings of decreased somatic activation in the stimulated nucleus favor these hypotheses . However, the increased output of projection neurons does not seem to be mediated by these phenomena . Another and currently favored hypothesis is that DBS overrides abnormal spike train patterns by an unphysiological, high-frequency pattern, and thereby masks pathological signals, which cause dysfunction of the remaining elements of the basal ganglia-thalamo-cortical and brainstem motor loop . The exact nature of the abnormal signals and the interaction between stimulation-induced neuronal responses and intrinsic brain activity remains elusive, but abnormalities of the firing rate and pattern of basal-ganglia neurons, changes in oscillatory activity and excessive synchronization at multiple levels of the motor loop have been proposed as pathophysiological correlates of motor symptoms in PD .
Am I A Good Candidate For Dbs
To determine if you are a good candidate, you:
Page reviewed by Dr. Chauncey Spears, Clinical Assistant Professor and Dr. Amelia Heston, Movement Disorders Fellow at the University of Michigan.
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