Wednesday, September 21, 2022

Indications For Dbs In Parkinson’s

Criteria For Deep Brain Stimulation Surgery

Deep Brain Stimulation (DBS) Indications & Limitations – Ausaf Bari, MD, PhD | UCLA Neurosurgery

An ideal candidate for DBS surgery is under 70 years old and is in good health. Patients who fluctuate between on and off medication states are usually good surgical candidates, as are those who have troublesome dyskinesias.

Your doctors will complete a formal evaluation to determine if you are a proper candidate for the surgery. The evaluation will including an MRI, physical and neurological testing, and an appointment with a neuropsychologist to ensure you are mentally and emotionally prepared for the procedure. Click here to complete the Are You A Candidate for DBS? questionnaire.

Deep Brain Stimulation At Michigan Medicine

For carefully selected patients with Parkinsons disease, Essential Tremor, and Dystonia, deep brain stimulation offers a therapeutic surgical option that can reduce or eliminate movement-related problems and greatly improve quality of life. At the University of Michigan Health System, our STIM program brings together a team of medical experts who are leaders in their respective fields and on the cutting-edge of the latest research.

What Is The Success Rate Of Deep Brain Stimulation

In general, deep brain stimulation is usually successful. The success rate depends on the condition involved. For conditions like epilepsy and Parkinson’s disease, DBS is very effective. More research is necessary for conditions where DBS is experimental before experts know if DBS is likely to help.

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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:

Can I Use Electrical And Electronic Devices If I Have Dbs Devices Implanted

PPT

In general, electronic devices and appliances shouldnt cause any problems with the pulse generator. If they do, the most likely effect is that your pulse generator will switch off. This might not have an immediate effect, but sometimes youll notice that your symptoms get worse, or you’ll notice an unpleasant feeling or sensation.

In general, you should keep in mind the following:

  • Your healthcare provider will give you two key items you should keep nearby whenever possible: an ID card and a patient programmer. The ID card can help you in situations with certain kinds of electronic devices like metal detectors or anti-theft scanners. The patient programmer allows you to turn the device on and off, plus adjust settings for the stimulation if needed.
  • Home appliances, such as microwaves, computers, smartphones and other common electronics, shouldnt cause any kind of interference or problems with your pulse generator.
  • Having one or more DBS leads and a pulse generator implanted in your body means you can’t have certain medical and diagnostic imaging procedures. The procedures you can’t have are magnetic resonance imaging scans, transcranial magnetic stimulation and diathermy.

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When Should I See My Healthcare Provider

Your healthcare provider will schedule visits to see you after your procedures. Programming visits occur with your neurologist, and youll need to make appointments to see them. The goal of those visits is to find the settings that work best and don’t cause side effects that disrupt your life.

Regular visits with your healthcare provider are also common to monitor your condition, symptoms and to adjust medications or other treatments as needed. The schedule for these visits is something that your provider will discuss with you.

What Is Deep Brain Stimulation Or Dbs

Deep brain stimulation, or DBS, is often described as a pacemaker for the brain. It works much like a pacemaker, sending electrical signals to the brain instead of the heart. DBS is primarily utilized for patients who have Parkinsons disease, dystonia, or essential tremor, and who cant adequately control their disease with medication. Before any patient is considered for the surgery, they are evaluated by the U-M interdisciplinary team. That team includes a neurosurgeon, neurologist, clinical neuropsychologist, speech pathologist, social worker, and other team members who ensure that you and your family understand the procedure and discuss your expectations and concerns.

Its important to understand that DBS does not offer a cure for your disease, but a way to manage it more effectively. It can offer many benefits, including the need to take less medication and therefore experience fewer medication side effects.

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What Happens During Deep Brain Stimulation

This procedure actually involves two to three surgeries that usually happen at different times. The first one or two procedures are to insert the stimulation leads into each side of your brain at the same or separate times. The second procedure is to implant the stimulator battery known as a pulse generator under the skin of your upper chest.

Before these surgeries happen, your healthcare provider will usually insert an intravenous line to give you IV fluids. An IV also allows them to give you medications during the procedure as needed.

Lead placement

This procedure usually starts with your healthcare provider shaving the hair on your scalp. This makes it easier to place your head into a special frame that will hold your head still. The frame is set with four pins in your skull. This is done while youre under sedation, and you likely wont remember this part.

Once the frame is set, theyll bring in an intra-operative CT scanner to take images of your brain and identify the trajectory used for the electrode placement. Once the CT scan is complete, the entry point is identified, sedation is turned back on and your head is cleaned with surgical prep. Local anesthetic is then injected to numb that area of your scalp and skull. Your neurosurgeon will then make a small cut .

Pulse generator placement

Is Your Patient A Candidate For Dbs Therapy

Deep Brain Stimulation (DBS) for Parkinson’s disease

Consider deep brain stimulation when a patient has:

  • Symptoms of levodopa-responsive Parkinson’s disease of at least 4 years’ duration that are not adequately controlled with medication.
  • And motor complications of recent onset or motor complications of longer-standing duration.

The safety and effectiveness of this therapy has not been established for the following:

  • Patients with neurological disease origins other than idiopathic Parkinsons disease
  • Patients with a previous surgical ablation procedure
  • Patients who are pregnant
  • Patients under the age of 18 years
  • Patients with dementia
  • Patients with moderate to severe depression

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Why A Doctor May Choose Deep Brain Stimulation

According to the National Parkinson Foundation, the ideal Parkinsons disease candidate for DBS surgery has:

  • PD symptoms that interfere with activities of daily living.

  • Fluctuations in mobility due to PD medications with or without dyskinesia .

  • Continued good response to PD medications, even if the medication effects may wear off sooner than they have in the past.

  • A history of several different combinations of PD medications while under the supervision of a neurologist specializing in movement disorders.

These factors* may make a person a less than ideal candidate for DBS surgery:

  • Difficulty with balance, walking, or freezing as the main disabling symptom.

  • A primary symptom of speech difficulty.

  • Continuous confusion and problems with memory and thinking.

  • A psychiatric condition such as depression or anxiety that has not improved or stabilized with other treatment.

  • Another condition that increases the risk for surgery complications.

*Some of these factors may be treatable. Having one or more does not disqualify a person for future DBS surgery, but the doctor may recommend more aggressive therapy focused on these issues before surgery takes place.

Indications And Presurgical Assessment

Criteria for selecting patients for GPi DBS for dystonia remain ambiguous.In general, surgical referral for all types of dystonia can be considered inpatients who have failed trials with anticholinergic drugs, benzodiazepines,and levodopa in generalized/segmental dystonia, or had no benefit or failurewith botulinum toxin injections in cranial and cervical dystonia. There iscurrently no widely accepted consensus about which type of medication, whichdose, or how many trials are needed before surgery. In general, it is notmandatory to have tried all available medications.

Symptoms should be disabling enough to justify the surgical risk. TheBurke-Fahn-Marsden Dystonia Rating ScaleReference Burke, Fahn, Marsden, Bressman, Moskowitz and Friedman17 and the Toronto Western Spasmodic Torticollis Rating ScaleReference Consky, Basinski, Belle, Ranawaya and Lang18 are two validated and widely used scales used to measure dystoniadisability and compare pre- and postoperatory outcomes. However, there is noagreement about which scales to use to assess symptoms, or which thresholdscores for disability, dystonia, and pain severity are needed for surgery.During the preoperatory assessment, it is generally important to considerusing quality of life scales, as this is often the main reason forsurgery.

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Research To Improve Deep Brain Stimulation

Researchers are working to improve upon existing DBS devices and methods to help treat more symptoms and more people. Some researchers are putting electrodes in a different area of the brain the pedunculopontine nucleus to treat walking and balance problems that don’t typically improve with present-day DBS. Others are developing a “smart” DBS device that can record a person’s unique brain signals and deliver electrical stimulation only when needed, such as when symptoms return, rather than continuously, as the current systems do. This could help reduce side effects such as numbness and weakness and lengthen the battery life of the neurostimulator, which would result in a longer time between battery replacement procedures.

Scientists also are planning to test deep brain stimulation in the first years after a Parkinson’s diagnosis to see if the therapy may slow or stop disease progression. Testing in Parkinson’s models showed the therapy may help protect brain cells, and a small human trial showed motor symptoms improved after early-stage DBS.

What Happens After Deep Brain Stimulation

Globus Pallidus Interna or Subthalamic Nucleus Deep Brain Stimulation ...

Your healthcare provider will schedule a follow-up appointment that will take place within a few weeks of the pulse generator implantation procedure. At this appointment, they’ll start programming the pulse generator.

All pulse generators now in use have a wireless antenna built-in. That allows your healthcare provider to access and program the device from outside your body. Finding the right settings for the pulse generator may take some time and additional visits for adjustments.

Most pulse generators have special batteries that have long lifespans. Standard batteries for these devices last about three to five years. Some devices use rechargeable batteries, which can last about nine years. Replacing the battery also takes a surgery procedure, but this is usually shorter and quicker than the original surgery to implant the pulse generator. You’ll still go home the same day for battery replacements.

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Why Is Dbs Used

There are billions of neurons in each human brain, and these cells communicate with each other using electrical and chemical signals. Several brain conditions can make neurons in different parts of your brain less active. When that happens, those parts of your brain dont work as well. Depending on the part of the brain affected, you can have disruptions in the abilities controlled in that area.

DBS uses an artificial electrical current to make those neurons more active, which can help with the symptoms of several different brain conditions. However, researchers still dont know exactly how or why this works.

Deep Brain Stimulation Surgery

A team of experts, including a movement disorder specialist and a brain surgeon, conducts an extensive assessment when considering DBS for someone. They review your medications and symptoms, examine you when you’re on and off Parkinson’s medication, and take brain imaging scans. They also may do detailed memory/thinking testing to detect any problems that could worsen with DBS. If your doctors do recommend you for DBS and you are considering the surgery, discuss with your care team the potential benefits as each person’s experience is unique. It’s also critical to discuss the potential surgical risks, including bleeding, stroke and infection.

In DBS surgery, the surgeon places thin wires called electrodes into one or both sides of the brain, in specific areas that control movement. Usually you remain awake during surgery so you can answer questions and perform certain tasks to make sure the electrodes are positioned correctly. Some medical centers now use brain imaging to guide the electrodes to the right spot while a person is asleep. Each method has its pros and cons and may not be suitable for everyone or available everywhere.

Once the electrodes are in place, the surgeon connects them to a battery-operated device , which usually is placed under the skin below the collarbone. This device, called a neurostimulator, delivers continuous electrical pulses through the electrodes.

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Incorporating Dbs: Barriers And Opportunities

DBS has traditionally been used to treat motor complications of levodopa therapy in advanced PD and found to be highly effective in improving motor function by greatly reducing the dyskinesias and off times and improving quality of life, according to Dr. DeLong. However, it is now recognized that earlier intervention in the mid-phase of PD, with the onset of motor complications, may both improve motor function and impact quality of life more effectively than best medical therapy alone. Regarding its clinical application, Dr. DeLong says that DBS should be considered in patients at the mid-phase of disease, when dyskinesias begin to appear. For these patients, DBS may offer impressive results. In fact, the similarity the two approaches offer in terms of efficacy is remarkable. The major advantage of DBS is that it provides similar benefits without the side effects of traditional therapies. DBS confers continuous stimulation, which can be particularly effective for off times. It also generally abolishes or greatly reduces the peak dose effects of dyskinesias, he says.

Benefits Of Medtronic Dbs

How does Deep Brain Stimulation (DBS) work?

HELPS CONTROL MOTOR FUNCTION AND IMPROVES QUALITY OF LIFE

  • Improves motor function and reduce medication for patients with recent or longer-standing motor complications1,2
  • Improves quality of life and activities of daily living for Parkinsons patients with recent or longer-standing onset of motor complications.1,2
  • Reduces medication and improves drug-related complications1
  • Offers the first safe* access to MRI anywhere on the body for diagnosing health conditions in patients with deep brain stimulation
  • Allows therapy to be turned off or reversed, preserving options for future therapies and treatments

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Patient Awareness And Communication

One problem that has become very clear over the last two decades since DBS has been available is its under-utilization. Put simply, the numbers of patients who are treated with DBS versus the number of patients who would benefit from it are not at all proportional, according to Dr. DeLong. Particularly with the expanded indication, he believes that more patients should be considered for DBS.

Any time something new is introduceda new idea, approach, theory, or discoverythere is always resistance and opposition initially, says Dr. DeLong. Right now, one of the key factors to the underuse of DBS is lack of understanding and awareness. Many patients who would benefit from this modality know very little about it and are not aware of its availability and the opportunities it presents. Whether this can be attributed to unwillingness from some physicians to consider DBS or patients who would prefer a more traditional approach is difficult to say, he notes. In all likelihood, there is probably an element of both.

Deep Brain Stimulation: Resources

To learn more about Deep Brain Stimulation, Medtronics website contains numerous resources for physicians, including information on acquiring training as well as patient selection. Additionally, the site offers access to peer presentations on DBS, procedure videos, details on reimbursement and prior authorization, as well as patient education resources for both pre- and post-implant care. Physicians can also find guidelines and manuals for various models.

Additionally, in some instances, DBS can offer benefits that medication does not. For example, With tremor, some patients do not respond at all to medication, whereas DBS has shown to be highly effective in this regard. When it comes to drug-induced dyskinesias, we have very few drugs that are effective. According to Dr. DeLong, amantadine is arguably the only one thats really proven to be of significance in this regard.

Regarding adverse events, Dr. DeLong observes that DBS carries a small, but significant risk to patients undergoing this procedure. Overall, there is a one percent risk of bleeding and possible neurologic deficit, resulting from placement of the stimulating electrodes. There is also about a five percent risk of infection involving the pacemaker and leads over the first five years, as well as a small risk of mechanical or lead breakdown, he observes. Therefore, the patient must weigh potential risks versus benefits in deciding on DBS.

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Theoretical Biology And Mechanisms Of Action

DBS is considered a well-established therapy for PD , even if its still unclear as to all of the biology and the actual mechanisms of action that underpin its benefits. Several theories have been proposed, implying that more than one mechanism is likely responsible for the therapeutic benefit.

Benabids group hypothesized that electrical stimulation induced an inhibition of basal ganglia output structures, decreasing basic firing of neurons and suppressing spontaneous neuronal activity . A reduction in activity in brain tissue surrounding the electrode, the possibility of depolarization blockade through K+ mediated effects , Na+channels inactivation , pre-synaptic depression of excitatory afferents , and hyperpolarization of neuronal bodies and dendrites have all been reported. Glutamate reduction with concomitant increases of inhibitory neurotransmitters such as GABA and adenosine may also play a role in the biology and mechanisms of action of DBS.

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