Brain Implant Surgery For Parkinson’s Disease

Less Medication More Relief

Medtronic DBS therapy may reduce the need for other Parkinsons medications1 and, consequently, medication-related side effects. DBS delivers therapy 24 hours a day and doesnt wear off while sleeping. Its already working when you wake up.

* Signal may not be present or measurable in all patients. Clinical benefits of brain sensing have not been established.

Parkinsons Patient First To Receive Brain Implant That Reverses Symptoms

A British hospital is the first in the world to implant a brain device that reverses the symptoms of Parkinsons disease. Now, its test patient is gushing over the results and says hes gotten his life back.

Surgeons at Southmead Hospital in Bristol are implementing a tiny deep brain stimulation device into the skull. It overrides the abnormal brain-cell firing patterns caused by Parkinsons.

Twenty-five Parkinsons disease patients have been selected for the trial at North Bristol NHS Trust that will finish next year. If the trial is successful, it will be possible to treat more Parkinsons patients more easily.

The trials first patient Tony Howells, who was diagnosed with Parkinsons nine years ago, said the impact was amazing.

Before the operation I went for a walk on Boxing Day with my wife and I got 200 yards from the actual car, he tells South West News Service. I had to turn around and go back because I just couldnt walk. Then after the operation, which was 12 months later, I went on Boxing Day again and we went for 2.5 miles and we couldve went further. It was amazing.

Parkinsons disease leads to parts of the brain becoming progressively damaged over years and currently has no cure. Symptoms include involuntary tremoring, slow movement, loss of automatic movement and stiff and inflexible muscles.

It takes just three hours to carry out the new operation, about half the time it used to with the larger battery.

Brain Implant Better Than Meds For Parkinsons Disease

• Story Highlights
• Brain implant gave Parkinsons patients more tremor-free hours daily than meds
• Deep brain stimulation delivers electrical impulses to movement control center
• Surgery is complicated, carries risks including infection, depression
• Treatment, introduced in 1990s, becoming more widely accepted
• Next Article in Health »

People with Parkinsons disease who have a pacemaker-like device implanted in the brain spend an extra four-plus hours a day free of tremors and involuntary movements than they do on medication, according to the largest study of the treatment, which is known as deep brain stimulation.

In deep brain stimulation, electrodes deliver impulses to the substantia nigra, which coordinates movement.

However, deep brain stimulation also has a correspondingly greater risk of problems, such as infection, because of the complicated surgery, according to the study published Tuesday in the Journal of the American Medical Association.

It definitely is brain surgery and that should give anyone pause, says David Charles, M.D., of Vanderbilt University, in Nashville, Tennessee, who was not involved in the new study. Nevertheless, he adds, most of the problems seen in the study were related to the surgery itself, and many had resolved themselves within six months.

When Parkinsons patients start a new drug, Weaver notes, they will see at best an hour or two more of on time a day.

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What Conditions And Symptoms Can Dbs Treat

DBS can treat several conditions that affect your brain, including movement disorders, mental health conditions and epilepsy.

DBS has approval from the U.S. Food and Drug Administration to treat the following conditions:

• Tourette syndrome.

It’s important to keep in mind that while the above conditions might benefit from DBS, experts still don’t know if this is the case. It usually takes years of research and clinical trials to determine if a medical procedure like DBS is helpful for conditions like these. While researchers are looking into them, DBS surgery to treat these conditions is not common.

Can I Use Electrical Devices

While you should be able to use most electronic devices, you should be aware that:

• Some devices, such as theft detectors and screening devices, like those found in airports, department stores, and public libraries, can cause your neurotransmitter to switch on or off. Usually, this only causes an uncomfortable sensation. However, your symptoms could get worse suddenly. Always carry the identification card given to you. With this, you may request assistance to bypass those devices.
• You will be able to use home appliances, computers, and cell phones. They do not usually interfere with your implanted stimulator.
• You will be provided with a magnet to activate and deactivate your stimulator. This magnet may damage televisions, credit cards, and computer discs. Always keep it at least 1 foot away from these items.

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Introduction of Clinical Question

Background

Parkinsons Disease is one of the most common conditions that present with orofacial dystonia and dyskinesia .

This leads to patients with the disease having trouble performing everyday activities such as eating, speaking and maintaining oral hygiene . Parkinsons Disease is more often seen in men than women and affects every 120 out of 100,000 people. There are two modes of this disease. The first is a genetic form which only consists of 5% of people with Parkinsons and occurs at a young age. The second occurs around the age of 57 and is deemed idiopathic as it has a more complex etiology where there is a familial and environmental component . Secondary Parkinsonism can be drug-induced. Parkinsons disease is caused by the death of dopaminergic neurons in the substantia nigra and locus coruleus. It is caused by the presence of Lewy bodies in the nerve cells in areas as such .

These neurons, which are subsequently destroyed, are necessary for the control of movement and coordination. Patients begin to experience symptoms once there is about a 65% reduction in functioning dopaminergic neurons .

Significance

Patients Presentation of Condition or Risk

Purpose Of Brain Surgery For Parkinsons Disease

Parkinsons disease surgery is used to treat motor effects of Parkinsons disease, such as tremor, but it does not help non-motor effects, such as reduced facial expression and dry skin.

Parkinsons disease can range from mild to severe, and it can be very disabling when the disease is severe. When high doses of medication are needed to control the symptoms, the medication can cause side effects such as dyskinesia , hallucinations, or both.

You might benefit from surgery if your symptoms do not improve adequately with medication or if you experience severe medication side effects.

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Living With A Dbs Device

Batteries most often last three to five years, but this can vary. Rechargeable batteries may last up to 15 years.

There are several precautions related to electrical/magnetic devices that are important, but usually easy to accommodate. Items such as cell phones, computers, and home appliances do not generally interfere with the stimulator. Keep your stimulator identification card handy when you are out and about, in your wallet or purse.

Theft Detectors

Be aware that some devices may cause your transmitter to turn on or off. This includes security monitors that might be found at the library and retail shops.

If this occurs accidentally, it is not usually serious, but may be uncomfortable or result in your symptoms worsening if the stimulator is turned off. When you visit stores with these devices, you can ask to bypass the device by presenting your stimulator identification card.

Home Electronics

Keep the magnet used to activate and deactivate the stimulator at least 12 inches away from televisions, computer disks, and credit cards, as the magnet could potentially damage these items.

Air Travel/Metal Detectors

Talk to TSA personnel when traveling by plane, as the metal in the stimulator may set off the detector. If you are asked to go through additional screening with a detector wand, its important to talk to the person screening you about your stimulator.

Medical Diagnosis and Treatment

Occupational Electromagnetic Concerns

Resources For More Information

• Surgical option a potential life-changer for patients with OCD: Read and watch Erins story as she, a lively 21-year-old woman, fought her battle with OCD. This article explores how deep brain stimulation gave Erin her life back. The procedure was the first of its kind performed at Albany Medical Center the only facility offering this treatment between New York and Boston. In Erins own words, Now, I can be who I really am and tell people my story and hopefully inspire people and help people along the way.
• Karen and Jims Story: A Shared Journey of Life, Love and DBS: Read about Karen and Jim. They were each diagnosed with Parkinsons before they met. Follow them on their journey as they fall in love after meeting each other from an online support group. See how they embraced each other and DBS.
• Kays Story A Parkinsons Disease Patient: Read about Kay, a 68-year-old woman suffering from Parkinsons disease. The article and video explore how DBS helped her regain her life. In Kays own words, Its like I had been turned on again. It was like a miracle.

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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.

What Happens During Dbs For Parkinsons Surgery

A neurosurgeon will implant the DBS system in two steps. First, he or she will place the thin wires that will carry electrical signals to precise areas of your brain. Second, the surgeon will place the small pacemaker-like device, or neurostimulator, under the skin of your chest.

Depending on your surgeon’s preference these steps can be either done in one day or two days over the course of a couple weeks.

The neurosurgeon will implant the following parts of your Medtronic DBS system under your skin:

• Very thin wires called leads deliver electrical signals from the neurostimulator to the brain
• The neurostimulator, also sometimes called a “battery” or “device”, that creates the electrical pulses that help control movement symptoms of Parkinson’s, including tremor, slowed movement, and stiffness

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What Happens During The Dbs Procedure

Most DBS procedures are performed with the patient awake under local anesthesia, with their head immobilized in a rigid frame, so that the surgical team can monitor patient response to the electrode placement as it occurs. A few centers are now offering image-guided placement, in which the surgery is performed under general anesthesia without the frame. The pulse generator is usually implanted during a second surgery, scheduled about a week after the first.

Patient Selection Presurgical Assessment And Safety

Patient selection should be carried out in designated centres by amultidisciplinary team including a movement disorders specialist,neurosurgeon, neuropsychologist, psychiatrist, neuroradiologist, and nurses,all experienced in DBS. DBS candidacy is usually established according toinclusion and exclusion criteria proposed by the core assessment program forsurgical interventional therapies in PD .Reference Defer, Widner, Marie, Remy and Levivier1 The following factors should be carefully assessed before advocatingsurgery to a given patient: disease duration, age, levodopa responsiveness,type and severity of levodopa-unresponsive symptoms, cognitive andpsychiatric issues, comorbid disorders, and brain magnetic resonance imaging findings. In the present article, we review and summarize the currentrecommendations for each given aspect.

Patients with unstable severe health issues are commonly not consideredsurgical candidates thus, there are no data regarding this subset ofpatients. However, although formal studies are lacking, seriouscomorbidities should be regarded as a contraindication to DBS given thenegative influence on the risk-benefit ratio.Reference Pollak5

In conclusion, several factors should be taken into account when consideringsurgery in PD patients and a thorough evaluation of the risk-benefit by aspecialized multidisciplinary team is mandatory in all cases.

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Selection Criteria: Clinical Evidence

The decision as to whether a patient with tremor is appropriate for DBS iscomplex and multifaceted.Reference Fasano, Herzog and Deuschl39,Reference Deuschl and Bain40 The first question is whether there is a chance for successfulmedical treatment. If the established medications at the highest tolerateddose have been tried without success, thensurgery might be considered. Two main factors have to be taken into accountat this point: the specific tremor condition and patients featuresReference Fasano, Herzog and Deuschl39 therefore, reaching the right diagnosis is one of the mostimportant factors in this process because many of those seeking surgery dueto the lack of benefit from medication are not in fact affected by tremoror, more importantly, have a functional tremor.

ET

Parkinsonian Tremor

PD patients might display severe resting tremor resistant to high doses of levodopa or disabling ET-like action tremor that does not respond to dopaminergic drugs.

Dystonic Tremor

Holmes Tremor

A recent report of ten patients with refractory Holmes tremor whounderwent either VIM or GPi DBS showed significant improvements for bothtargets of stimulation with an average improvement of 64%, sustained at 2years follow-up. Of importance, the choice of target was based resultsof intraoperative stimulation.Reference Espinoza Martinez, Arango and Fonoff43

Multiple SclerosisAssociated Tremor

Other Cerebellar Tremors

Tremor in Peripheral Neuropathy

Orthostatic Tremor

Palatal Tremor

Living With A Stimulator

Once the DBS has been programmed, you are sent home with instructions for adjusting your own stimulation. The handheld controller allows you turn the stimulator on and off, select programs, and adjust the strength of the stimulation. Most patients keep their DBS system turned on 24 hours day and night. Some patients with essential tremor can use it during the day and turn off the system before bedtime. Your doctor may alter the settings on follow-up visits if necessary.

If your DBS has a rechargeable battery, you will need to use a charging unit. On average charging time is 1 to 2 hours per week. You will have a choice of either a primary cell battery or a rechargeable unit and you should discuss this with you surgeon prior to surgery.

Just like a cardiac pacemaker, other devices such as cellular phones, pagers, microwaves, security doors, and anti theft sensors will not affect your stimulator. Be sure to carry your Implanted Device Identification card when flying, since the device is detected at airport security gates.

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What Is Parkinsons Disease Surgery

Parkinson’s disease surgery is a brain operation called deep brain stimulation . The surgery is also used to treat epilepsy, obsessive-compulsive disorder and a condition called “essential tremor.” DBS is widely considered one of the most significant neurological breakthroughs in recent history, posing a potential treatment for major depressive disorder, stroke recovery and addiction. Parkinson’s disease brain surgery aims to interrupt problematic electrical signals from targeted areas in the brain and reduce PD symptoms.

What To Expect On The Day Of Surgery

When you go for your surgery, you will meet with a nurse and have your vital signs checked. You will have an intravenous line placed in a vein, most likely in your arm. You will meet with your anesthesiologist and your surgeon, and you will be taken to the operating room.

Before your surgery, your head will be shaved and cleansed with a sterile solution if you are having invasive surgery. If you are having a device implanted in your brain, you will also have a generator implanted in your chest or abdomen, and this area will be cleansed as well.

You may have general anesthesia or local anesthesia and light sedation. If you are having general anesthesia, you will be put to sleep and you will have a tube placed in your throat to help you breathe. If you are having local anesthesia and light sedation, you will receive medication to make you drowsy, but you will be able to breathe on your own.

During your surgery, you will not feel any pain. Your doctors will monitor your vital signs throughout your procedure. Often, the surgery is done with imaging guidance, and sometimes it is done with electrical signal monitoring of the brain as well.

For some procedures, your surgeon will make a cut in the skin of your scalp and then will make a cut into your skull bone, as follows:

After your surgery is complete, your anesthetic medication will be stopped or reversed. If you have been intubated , this will be removed, and you will be able to breathe on your own.

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When Should I Call My Healthcare Provider Or Go To The Hospital

Because DBS involves surgery especially the procedure on your brain there are some warning signs you shouldn’t ignore. You should call your healthcare provider immediately or go to the hospital outside of business hours if you have the following symptoms:

• Severe headache that happens suddenly or wont go away.
• Bleeding from your incisions.