Who Is Not A Good Candidate For Dbs
You are not a good candidate for DBS if:
- You do not have a clear diagnosis of Parkinson’s disease.
- You have Parkinsons plus or an atypical form of the disease. Parkinsons plus disorders include multiple system atrophy, progressive supranuclear palsy and vascular parkinsonism. DBS might make these disorders worse.
- You have certain brain conditions, such as ischemic brain disease, demyelinating brain disease or brain tumors.
- You are not healthy enough for surgery.
If you are evaluated for DBS and not a candidate, your OHSU movement disorders neurologist will recommend other options.
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.
Deep Brain Stimulation For The Treatment Of Parkinsons Disease And Other Movement Disorders
Parkinson’s disease is a neurodegenerative disorder that leads to resting tremor, rigidity, slowness of movement, and postural instability. These symptoms are caused by degeneration of neurons in the substantia nigra pars compacta , one of a group of brain structures known as the basal ganglia and part of a circuit crucial for coordinating purposeful movement. This circuit relies on the chemical messenger dopamine, which is produced by SNc neurons. As PD progresses and these neurons are lost, reduced dopamine results in abnormal circuit activity and motor symptoms.
The molecular precursor to dopamine, L-DOPA , is used to treat PD. However, people in later stages of the disease experience off periods when this medication does not work well, and L-DOPA treatment can also trigger uncontrolled involuntary movement, a condition called dyskinesia. deep brain stimulation can offer symptomatic relief in later stages of PD and may reduce requirements for L-DOPA treatment and exposure to its side effects. DBS is also used to treat other movement disorders, including essential tremor, which causes involuntary shaking that worsens during movement, and dystonia, which causes involuntary muscle contractions and slow, repetitive movements or abnormal postures.
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Symptom Profiles That May Or May Not Benefit From Dbs
Data derived from the available randomized DBS studies suggest that PD patients with medication-refractory and difficult to control onoff fluctuations may be the best candidates for DBS therapy . In the UK PD Surge trial, the authors collected information on the main reasons why patients considered DBS surgery. Severe offs, dyskinesia, and tremor were the most commonly cited indications . Although it is now well-established that levodopa-responsive symptoms of PD have the greatest response to surgical interventions, the effect of disease progression may not be routinely included in preoperative patient discussions, where risks and benefits can be thoroughly vetted. Discussions with patients should routinely involve the realization that walking, talking and thinking could worsen not only from stimulation- or lesion-induced effects, but also as a result of disease progression . Patients with highly asymmetric symptoms may need only a single-sided DBS operation, and in these cases taking a conservative approach to therapy may improve the riskbenefit ratio .
Finally, one must also consider whether a medication reduction may be useful in cases with medication-related psychosis or behavioral issues, which may impact target choice or unilateral versus bilateral implantation.
Does Insurance Cover Deep Brain Stimulation
Many insurances will cover DBS, especially if it has official approval to treat that condition. Its important that you contact your insurance company to learn if they cover DBS procedures in any way.
A note from Cleveland Clinic
Deep brain stimulation is a treatment option that can help with a wide range of conditions that affect your brain function and mental health. Its almost always an option after other treatments and methods are unsuccessful. Its most common for conditions like Parkinsons disease and epilepsy, but researchers are also exploring the possibility of using it to treat many other conditions. While it does involve two to three surgeries, its also very effective at helping reduce symptoms and treat conditions that severely affect your quality of life.
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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.
Dbs Versus Apomorphine Duodopa Stem Cell Trials & Gene Therapy Trials
There is little available data comparing DBS to other surgical interventions, such as apomorphine pumps, duodopa pumps or to stem cell and gene-therapy approaches. The lack of data often leaves the clinician in a difficult position when attempting to compare standard versus investigational therapies for an individual patient. The UK PD Surge trial did provide some limited data suggesting that in patients still having difficulties post-apomorphine pump placement, DBS may represent a reasonable approach . Future comparative trials, especially of apomorphine and duodopa therapy may help to elucidate which phenotype of patients may be the most appropriate for each type of therapy. The lack of data and lack of approval beyond research for stem cells and gene therapy make comparison with DBS difficult.
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Efficacy Of Segmented Versus Conventional Electrodes
VTA can be modified according to requirement by using segmented electrodes instead of cylindrical ones, as this allows field steering and independent control over electrode contacts.9,60,61 The segmented electrodes have a better design, lesser side effects, and cause lesser activation of surrounding tissue than cylindrical ones hence they provide a larger therapeutic window and give the time to clinicians to modify side-effect thresholds.9,60,61
Risks And Side Effects Of Deep Brain Stimulation
Like any surgery, deep brain stimulation can have side effects, and it carries potential risks. Its also important to consider the complications and side effects of medications you take since their dosages can often be reduced following surgery.
While DBS may cause side effects, it may also reduce side effects from medications.
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Sites Of Deep Brain Stimulation And Symptom Control
While both subthalamic nucleus and globus pallidus internus stimulation help improve the motor symptoms of Parkinsons disease, studies have found a few differences.
DBS of the third target, the ventral intermediate nucleus, can be beneficial for controlling tremors but does not work as well at addressing the other motor symptoms of Parkinsons disease.
In a Canadian study, targeting the subthalamic nucleus allowed people to reduce the doses of their medications to a greater degree, while targeting the globus pallidus internus was more effective for abnormal movements .
In another study, STN deep brain stimulation also led to a greater reduction in medication dosages. However, GPi stimulation resulted in greater improvement in quality of life, and also appeared to help with the fluency of speech and depression symptoms.
Side effects of DBS can sometimes include subtle cognitive changes . A different study compared these effects with regard to these different areas.
GPi showed smaller neurocognitive declines than STN, though the effects were small with both. On a positive note, both procedures seemed to reduce symptoms of depression following surgery.
What Are The Risks
No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Complications related to placement of the DBS lead include seizures, infection, and a 1% chance of bleeding in the brain.
Reasons for which you might need additional surgery include breakage of the extension wire in the neck parts may wear through the skin and removal of the device due to infection or mechanical failure. If you have a non-rechargeable DBS system, the battery will need to be replaced every 3 to 5 years. Rechargeable DBS systems have a battery that lasts 10 to 15 years.
DBS may also cause worsening of some symptoms such as speech and balance impairments. In some patients with Parkinson’s, DBS may cause or worsen depression. If you develop any side effects from a stimulation adjustment, you need to return to the office for further programming.
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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 .
What Are The Risks Or Complications Of Dbs
Because DBS does involve surgery, there are some possible complications and risks. Your healthcare provider is the best person to tell you about the possible risks and complications. They’re the best source of information because they can consider your medical history, circumstances and more.
The possible complications of surgery include:
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Deep Brain Stimulation In Parkinsons Diseaserecent Advances
- Lilach Soreq, PhD Institute of Neurology, University College London, Queen Square, London, UK The Francis Crick Institute, Somers Town, London, UKInterests: aging alzheimers disease bioinformatics deep brain stimulation statistics microRNAs microarrays parkinsons disease RNA-Seq Special Issues in IMR Press journals
Dear Colleagues,
Parkinsons disease is a devastating condition with unknown causes/underlying mechanisms. During my PhD, I studied RNA expression in PD patients using 3 exon and junction arrays and SOLID small and long read RNA-Seq. This was done prior to and following deep brain stimulation neurosurgery, both on and off electrical stimulation. Reversible expression changes were found in several microRNAs. Gene Ontology biological process and molecular function analysis of the data was also performed using non-parametric Kolmogorov-Smirnov statistics. Changes in metal ion binding, apoptosis and alternative splicing processes were detected. Statistical tests were applied to the data, as well as classification methods. I found that specific genes were altered in PD patients compared to control patients, including previously reported PD genes such as Park1 and SNCA.
Dr. Lilach Soreq
How Does Dbs Work
In DBS surgery, electrodes are inserted into a targeted area of the brain, using MRI and, at times, recordings of brain cell activity during the procedure. A second procedure is performed to implant an impulse generator battery , which is similar to a heart pacemaker and approximately the size of a stopwatch.
The IPG is placed under the collarbone or in the abdomen and delivers an electrical stimulation to targeted areas in the brain that control movement. Those who undergo DBS surgery are given a controller to turn the device on or off and review basic parameters such as battery life.
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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.
Benefits Of Medtronic Dbs
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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Key Issues In Maximizing Dbs Benefit
The maximizing of DBS benefits may be influenced by target selection and by laterality.
Utilizing unilateral DBS
Highly asymmetric PD features and especially patients with lower UPDRS motor scores may be addressed with unilateral DBS . If a single DBS lead is utilized, there is some evidence that quality of life improvements may be more robust with unilateral GPi DBS and the chances of staying unilateral may also be better with GPi .
Tremor, rigidity, bradykinesia & dystonia
Most available randomized data support similar improvements for unilateral and bilateral STN or GPi DBS for tremor, rigidity, bradykinesia and dystonia . One study revealed a slight benefit in rigidity with unilateral STN DBS . However, some centers have leaned toward STN DBS for tremor control, although this point has not been strongly supported by the available randomized studies . When implanting DBS devices for tremor, many centers attempt to place the active contacts on the DBS lead more posterior in both the GPi and the STN targets. However, when moving posterior in the GPi, however, one may encounter capsular side effects. Therefore, the capsular side-effect profile, along with the overall larger size of the GPi target have led some centers to lean toward STN DBS in severe tremor cases.
Levodopa-responsive gait & balance issues
Medication reduction/increase
On time, onoff fluctuations & dyskinesia
Quality of life
How Does Deep Brain Stimulation Work
Movement-related symptoms of Parkinsons disease and other neurological conditions are caused by disorganized electrical signals in the areas of the brain that control movement. When successful, DBS interrupts the irregular signals that cause tremors and other movement symptoms.
After a series of tests that determines the optimal placement, neurosurgeons implant one or more wires, called leads, inside the brain. The leads are connected with an insulated wire extension to a very small neurostimulator implanted under the persons collarbone, similar to a heart pacemaker. Continuous pulses of electric current from the neurostimulator pass through the leads and into the brain.
A few weeks after the neurostimulator has been in place, the doctor programs it to deliver an electrical signal. This programming process may take more than one visit over a period of weeks or months to ensure the current is properly adjusted and providing effective results. In adjusting the device, the doctor seeks an optimal balance between improving symptom control and limiting side effects.
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The Many Ways To Define Early Dbs & How Early Is Too Early
A recent study suggested that DBS in less advanced cases may be feasible and efficacious . Trials published in the literature to date have not included patients with short disease durations or patients without motor fluctuations. The neuroprotective effects of surgery have not been substantiated, and thus cannot be ethically used to argue for earlier intervention in individual patients. There is a solid argument evolving for cost savings with early DBS. However, arguments based on motor, non-motor and quality of life features have less of an evidence base at this time. Better methodologically constructed and adequately powered clinical trials with carefully conceived end points will need to be performed in order to settle the questions surrounding early DBS intervention.
Early DBS covers several scenarios. Consider the example of a 60-year-old patient diagnosed with PD 24 years prior, experiencing life-altering disability from tremor, despite maximal combinations of levodopa, dopamine agonists and anticholinergics. Most clinicians and multidisciplinary surgical teams would agree that this could be a reasonable case for early intervention.
In our opinion, the most controversial scenarios for early intervention are:
We believe that patients who fall into these above categories should, in most cases, have DBS performed only in the context of an Institutional Review Board-approved clinical research trial.