Deep Brain Stimulation For Parkinson’s May Help Long Term
THURSDAY, June 3, 2021 — Parkinson’s disease patients can get symptom relief with deep brain stimulation therapy that lasts over the long term, a new study shows.
Over 15 years, patients who received DBS, which requires surgical implantation, had significant improvement in motor symptoms and less need for medication, researchers found.
“Our study, for the first time, supports the efficacy of deep brain stimulation in the very long term — 15 years after surgery and 25 years since Parkinson’s diagnosis,” said senior researcher Dr. Elena Moro, director of the Movement Disorders Unit at Grenoble Alpes University in France.
“Indeed, after an average of 15 years after surgery, patients could experience improvement, compared to before surgery,” she said. “Moreover, we could still observe a marked reduction of anti-Parkinson’s medication and improvement of quality of life, compared with before the intervention.”
Patients with Parkinson’s disease no longer make dopamine, which affects their speech, walking and balance. Symptoms can be partially relieved by the drug levodopa, which temporarily restores dopamine.
But as levels of dopamine fluctuate during the day, patients can suffer from dyskinesia, a side effect of levodopa that can cause twisting, swaying or head bobbing.
For the study, Moro’s team collected data on 51 patients being treated with DBS. On average, they had the device for 17 years.
Will I Be Asleep During The Entire Procedure
You will be sedated or receive local anesthesia for part of the procedure, may or may not be awake for lead and electrode placement, and will be asleep when the impulse generator is implanted. To provide more details:
- A local anesthetic is applied to areas of the head where pins or screws are used to secure the head frame and sedation is given.
- You will be sedated during the beginning of the procedure, while the surgical team is opening the skin and drilling the opening in the skull for placement of the lead.
- Most patients will be awake for lead and electrode placement. This part of the procedure is not painful, as the brain does not feel pain. Being awake allows the surgical team to interact with you when testing the effects of the stimulation. However, some patients who cannot tolerate the procedure while awake can have the electrode and lead placed under general anesthesia. The lead placement is guided in real time by magnetic resonance imaging. The procedure is performed in a special MR-equipped operation room.
- Implantation of the pulse generator in the chest and connection of the leads from the device to the lead in the brain is usually done under general anesthesia.
When Is A Good Time To Consider Dbs Am I A Good Candidate
There are somewhat different criteria for determining if DBS is a good option for you based on your diagnosis and condition. For Parkinsons disease, DBS is typically helpful if you experience motor fluctuations or tremors that interfere with activities that are not already adequately managed by medication, are not improved by changes in medication, or you experience side effects that prevent you from taking higher doses. For ET, DBS may be considered if you have tremors that interfere with your quality of life and cannot be controlled adequately with medications. Other key factors considered are age in combination with general health, a solid support system of family and friends, absence of dementia or an active psychiatric illness such as severe depression, and realistic expectations for treatment outcomes.
Before any patient is considered for DBS surgery, they are evaluated by the U-M Surgical Therapies Improving Movement multidisciplinary team, which has extensive training in DBS. The STIM 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.
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Can You Drive After Dbs Surgery
The majority of patients resumed driving shortly after DBS surgery. Three months preoperatively, 66 of the 110 patients were active drivers, but 64.7% of patients expected at that time to be able to drive postoperatively. 50.9% of all patients resumed driving within a postoperative period of 3 months.
What Is Deep Brain Stimulation For Parkinsons Disease
DBS is electrical stimulation of the brain by using a small machine. DBS can stimulate many brain areas.
DBS is actually approved for many diseases. It is not just a Parkinsons surgery. It can be used for epilepsy and other movement disorders as well.
The basic setup is the same.
The DBS battery is inserted below the chest skin. Two small wires from the battery go up to the head. The wires go through the skull. They are inserted into the desired area of the brain.
For Parkinsons disease: This target area of the brain is usually the Subthalamic Nucleus .
In some patients, another area is chosen as the target. This other area is the Globus Pallidus interna .
How is the target chosen? Read this article
DBS can dramatically improve Parkinsons symptoms. There are many before-after videos available on the internet.
For example, here is a video posted on youtube by the Neuromedical Center in USA.
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Deep Brain Stimulation: How Awake Brain Surgery Works
Parkinsons disease makes it hard to do many things that people without the condition take for granted.; A disorder of the nervous system, Parkinsons affects movement and often includes tremorsuncontrollable shaking of the hands or other body parts that can turn patients lives upside down, robbing them of the motion control they need to do their jobs, or simple tasks like brushing their teeth. Many patients can manage their tremors with medication, but for some, the treatment becomes less effective over time.
There is hope. Deep Brain Stimulation is a surgery that canalmost instantaneously in the operating roomstop the tremors. Its the use of stimulation within nuclei deep inside the brain to try to correct dysfunction within neurological circuits, explains Jason Gerrard, MD, chief of functional neurosurgery at Yale.
The procedure involves implanting one or more electrodes into specific areas in the brain associated with the movement disorder. The electrodes, controlled by an external stimulator, send electrical impulses that regulate abnormal or overactive impulses.
Early on, it was identified in Parkinsons disease that neurons within the substantia nigra were being lost, says Dr. Gerrard. And these neurons were known to contain the neurotransmitter dopamine.
What Kind Of Results Can You Expect After Having Dbs
A few weeks after the surgery, a specialist will program the DBS settings to your symptoms.
Surgery To Implant The Deep Brain Stimulation Device
Precise Placement During Dbs Surgery
But the procedure would have to wait. The coronavirus pandemic shut down elective surgeries across Colorado, then throttled them back later in 2020. It would be January 2021 until the procedures took place.
Deep-brain stimulation surgery for Craig involved three procedures. During the first and second, doctors implanted the electrodes on the right and left sides of Craigs brain. During the third procedure, the specialists placed the battery under the skin just below the collarbone.
Three subspecialists collaborated prior to and in the operating room for placement of the DBS electrodes: ;the movement-disorders neurologist , the neurophysiologist who aides in determining the location of the electrode based upon hearing and watching brain cells fire ); and the stereotactic functional neurosurgeon . University of Colorado Hospital is among a select few U.S. medical centers bringing such a comprehensive array of skills to the DBS operating room.
In early April, the Overmans were back at the hospital for Kern to program the DBS device. This was one of the several 330-mile trips he had already made. Programming involves adjusting the amount and location of electrical current flowing to Craigs subthalamic nucleus. Susan took cell phone videos of her husband walking down a hallway before and after the roughly 90-minute session. Before, he shuffles slowly and stiffly with baby steps; after, his strides are healthy and his gait appears nearly normal.
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Correlation Of Active Electrode Contacts With Microrecordings
To account for individual variability within the basal ganglia and the subthalamic area, the position of single electrode contacts should preferentially be put in relation to the location of the structures of interest. For that purpose, we developed an algorithm for three dimensional plotting of the electrode contact within the same stereotactic coordinate system, showing the microrecording tracks explored intraoperatively . The intercommissural plane is indicated for orientation purposes, while the three dimensional plots can be rotated to be viewed from different angles of interest. The area where subthalamic nucleus activity was first recorded and which corresponds to its dorsal margin was defined by retrospective off-line analysis of intraoperative microrecordings . Despite continuous on-line analysis during the operation, recordings of longer duration used for off-line reassessments had been made at intervals of 0.5 mm. This results in some uncertainty over the exact location of the border. Taking the length of single electrode contacts into account as well , contacts located within ± 1.0 mm from the neurophysiologically mapped subthalamic nucleus margin were categorised as being located in the border area.
Active electrode contacts relative to the margin of the subthalamic nucleus
Will I Be Asleep During The Deep Brain Stimulation Procedure
How Do I Know If Im A Candidate For Deep Brain Stimulation
Levodopa response test
Reduces Dyskinesia And Fluctuations
Medtronic DBS therapy reduces complications of drug therapy, such as dyskinesia and fluctuations in on and off time.3,4,5,6 Medtronic DBS therapy reduces complications of drug therapy by 37% to 61% compared to medication alone.4,5 Without DBS, people receiving best medical therapy experience between a 5.4% reduction to a 13% increase in drug-related complications compared with their baseline.4,5
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What Are The Benefits Of Placing The Electrodes Under Anesthesia
Performing the brain surgery while the patient is anesthetized and unconscious is faster and safer. Patients also can take their medication prior to surgery.
Conventional deep brain stimulation required patients to respond to the neurosurgeons instructions to help place the electrodes properly. Your neurosurgeon now can plan ahead of time where to place the electrodes, using high-resolution scans that map the brain.
What Does Dbs Feel Like When The Device Is On
During the initial programming of the DBS, individuals may experience a slight, temporary shock or tingling as placement and levels are adjusted. Identifying the best placement and level enables you to receive the greatest benefit possible based on your unique condition and needs.
Most individuals feel little if any sensation at all during normal use. For the few that do, it is described as a slight tingling down an arm or leg, or mild facial pulling which subsides. This is more common in individuals using DBS for essential tremor as the device can be turned off at bedtime.;
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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.
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:
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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 Parkinson’s 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.
Why It Is Done
Deep brain stimulation may be used to relieve symptoms of Parkinsons disease, especially tremor, when they cannot be controlled with medicine. It is considered the surgical treatment of choice for Parkinsons disease, because it is more effective, safer, and less destructive to brain tissue than other surgical methods.
Deep brain stimulation of the thalamus is done to treat both disabling tremor caused by Parkinsons disease and essential tremor.
Procedures that stimulate the subthalamic nucleus and the globus pallidus are done to help control a wider range of symptoms and are used more often than stimulation of the thalamus. Symptoms that are most often helped include problems with changes between on and off time and dyskinesia. Symptoms that are less likely to get better include problems with walking, balance, and speech. In some cases, DBS can make these problems worse.
Deep brain stimulation may also be used to treat severe tremor related to multiple sclerosis . Deep brain stimulation usually is a last resort after all other options have been tried without success to treat MS tremor. Only people with severe tremor are candidates.
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What Are The Risks And Complications Of Deep Brain Stimulation
As with any surgical procedure, there are risks and complications. Complications of DBS fall into three categories: surgery complications, hardware complications, and stimulation-related complications.
- Surgical complications include brain hemorrhage, brain infection, wrong location of the DBS leads, and less than the best location of the leads.
- Hardware complications include movement of the leads, lead failure, failure of any part of the DBS system, pain over the pulse generator device, battery failure, infection around the device and the device breaking through the skin as the thickness of skin and fat layer change as one ages.
- Stimulation-related complications occur in all patients during the device programming stage. Common side effects are unintended movements , freezing , worsening of balance and gait, speech disturbance, involuntary muscle contractions, numbness and tingling , and double vision . These side effects are reversible when the device is adjusted.
What Goes Wrong In Parkinsons
In Parkinsons, dopamine-producing cells in the substantia nigra, slowly stop working properly and are lost over time. Without the injection of dopamine these cells provide, it becomes harder to get moving and to maintain movements so, things like stride length can get shorter over time.
So if you imagine that our movement is controlled in a similar way to a car, then you can think of the substantia nigra playing the role of the accelerator pedal and dopamine is the chemical needed push the accelerator down.
So when these brain cells start struggling to produce enough dopamine , it becomes harder and harder to push down on the accelerator and get moving. Thats where Parkinsons medication can really help, by boosting dopamine levels, these drugs can make it easier to push down the accelerator again and help people to move.
However, medications that boost dopamine are not a perfect solution because as brain cells in substantia nigra continue to struggle and be lost over time, more drugs are needed and keeping dopamine levels in the sweet spot to control symptoms becomes more and more difficult. The swings in dopamine levels in the brain mean that movement control becomes more erratic and unpredictable.
Going back to our car analogy, its like jabbing the accelerator pedal so the car moves in a stop/start fashion.
At this point, sometimes a type of surgery called deep brain stimulation , can be a good option.
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