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.
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Rigorous Testing For Safe Access To Mri
Approximately seven out of 10 DBS-eligible patients with movement disorders may need an MRI within 10 years of receiving their device.1 Only Medtronic provides safe* access to MRI anywhere on the body with some systems under certain conditions giving your doctor an important tool for diagnosis. We know its important that you have safe access to MRI. Thats why we performed rigorous testing of Medtronic DBS systems.
- 14 years of MRI research and testing
- 10 million simulated patient scans performed using 38,800 scan conditions such as patient size and patient position within the MRI machine
Some Medtronic DBS devices may remain on while you have an MRI. You may take comfort in knowing that the device can remain on to control your symptoms. Talk with your doctor before having an MRI.
Be More Active Like Gilles
Since I had the operation my life is much, much better. Ive got a kind of energy again, the way others look at me has completely changed.
Gilles from France, Deep Brain Stimulation story
Gilles has been able to reduce his Parkinsons medication and continue working as a journalist after having DBS surgery.
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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:
- 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.
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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Parkinsons Disease Dbs Surgery
Deep Brain Stimulation is a surgical treatment involving implantation of electrodes into deep structures of the brain involved in motor control.
The Food and Drug Administration approved DBS as a treatment for Parkinsons disease in 2002, but the first DBS surgery was done about 10 years prior. Electrodes are placed in the area of the brain involving motor control, and are connected to a programmable pacemaker-like device implanted under the skin in the chest wall. While it does not cure the disease, it can dramatically improve many symptoms associated with PD and patients quality of life.
Is DBS Right For You?
It is important to understand that DBS is not successful in treating all symptoms of PD. It is a proven and effective treatment for motor problems, caused by PD slowness, muscle stiffness, tremor, etc. Most non-motor symptoms of the disease, including cognitive decline, mood and behavior problems etc.., would not be expected to respond to DBS. In addition, balance problems and freezing of gait do not always improve with DBS.
Risks of DBS
Supporting You Throughout Treatment
When you have Medtronic DBS Therapy , our world-class support team is always available to ensure you are getting the most out of your therapy. Our representatives are located all over the United States so youre never far from someone who can help.
- As always with your medical care, your doctor should be your first call. We support your doctor with 24/7 technical support, training, therapy updates, extensive online resources, and local Medtronic representatives.
- Our online directory of neurologists who specialize in Parkinsons and DBS therapy will continue to be a great resource if you move or travel.
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Stimulation Data And Safety
All patients had received subthalamic deep brain stimulation. Three months after surgery mean stimulation settings were 2.4 ± 1.0 mA, 128.4 ± 9.5 Hz, 59.3 ± 3.3 s for the left STN and 2.2 ± 0.9 mA, 154.7 ± 176.4 Hz, 59.8 ± 3.3 s for the right STN. At 12-MFU the settings were 3.0 ± 1.0 mA, 133.6 ± 23.1 Hz, 57.6 ± 8 s for the left STN and 2.8 ± 0.9 mA, 133.6 ± 23.1 Hz, 60 ± 9 s for the right STN. In the first year after implantation, seven adverse events occurred including dyskinesia , dysarthria and accidental STIM-OFF . One patient with dyskinesia needed a transient stimulation pause directly after stimulation. Dyskinesia and dysarthria was each responsive to stimulation adjustments. In the patient with accidental STIM-OFF, no defect could be found after reactivation of stimulation and AE did not occur again. Nine serious adverse events occurred in this cohort: One patient with impaired wound-healing improved under antibiotics, one patient needed 24 h observation time after a fall with associated head trauma but without damage to the system, three patients experienced postoperative confusion that resolved spontaneously after 35 days and one patient suffered from intracranial bleeding around one electrode with associated aphasia that remitted incompletely up to 12 MFU. One patient attempted suicide after newly started DA-therapy and resulting impulsivity 11 months after electrode implantation.
What Is Deep Brain Stimulation And How Does It Work
DBS is a therapy that we have for various neurological conditions, said Dr. Sheth. It’s a system that you can think of like a pacemaker. But rather than being a pacemaker for the heart, it’s for the brain.
Dr. Sheth describes the brain as having many circuits that govern everything we do, including how we move.
If the movement circuit is not working properly, we may have a movement disorder like Parkinson’s, he said. If we can identify the circuit within the brain that is not working properly, we can use this device to reset the rhythms in the brain and restore the balance so that our movements can be better controlled or without a tremor.
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Less Medication More You
DBS therapy is an implanted solution that provides more relief, not more medication. Many people with Parkinsons disease take multiple doses of multiple medications. Keeping track of medications can be difficult. Some find that they must increase the number and frequency of doses to get the same relief. Others find that the more medications they take, the less the medications seem to work. DBS is not a medication and it does not contain medication. In many cases, DBS therapy helps patients reduce the amount of their Parkinsons drugs by up to 50%.2
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
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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How Is Deep Brain Stimulation Performed
Before the actual procedure begins, for most patients, a head frame is positioned on your head, which keeps your head still during brain imaging and is used to deliver the electrode to the target in the brain. Surgical pins or screws are used to secure the frame to your head. Sedation is typically given during this portion of the procedure.
Your neurosurgeon will implant the deep brain stimulation system in one to three stages.
First, a small hole is made in the skull. The leads, which have electrodes at the ends, are passed through this hole and surgically implanted in the areas of the brain identified as the site responsible for the movements caused by Parkinsons disease.
Most people with Parkinsons disease will require one lead placed on each side of the brain unless symptoms are mostly one-sided . Each side of the brain controls the opposite side of the body, so each lead is inserted on the opposite side of where symptoms are occurring. Sometimes this procedure is done in stages one lead is placed at one time followed by another surgery for the other side. In other patients, both leads are placed during the same operation. Many times patients are awake during lead insertion. An intraoperative MRI is also sometimes used to image the lead location.
Are You A Good Candidate For Dbs
The best candidates for DBS surgery are people who:
- Have been diagnosed with Parkinson’s for five years or more
- Have disabling tremors and dyskinesias or severe motor fluctuations
- Experience severe motor fluctuations that cannot be controlled with adjustments to medication schedules
- Often experience significant dyskinesias interspersed with rapids wearing off and off time crises throughout the day
Not everyone is a good candidate for this surgery. It is important to know that some Parkinson’s symptoms respond well to DBS and others do not. The decision to undergo surgery depends on a critical assessment of each person’s specific symptoms.
Symptoms that respond well to intervention include:
- Dystonia (sustained or repetitive muscle twisting, spasm or cramp
Several factors influence the outcome of DBS. One of the best forecasts is your response to levodopa. People whose symptoms still respond well to individual doses of the drug and who have mobility during their “on” periods usually have better results with DBS.
While some people think DBS should not be considered until Parkinson’s medications have become completely ineffective, this is not true. When medications stop working completely, deep brain stimulation won’t work, either. Surgery promises more effectiveness for those who experience complications with medications, such as dyskinesias, but continue to respond well to levodopa.
Those who respond well to DBS tend to be people who:
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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.
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 .
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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
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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Conditions Treated With Deep Brain Stimulation Surgery
Deep brain stimulation surgery effectively provides relief from the symptoms of various movement disorders. Some of the diseases in which the procedure is approved are:
Research is underway to expand the use of this procedure in various other neurological conditions. These are Alzheimers disease, Traumatic brain injury, multiple sclerosis, Anorexia Nervosa, depression and chronic pain.
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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