Parkinson’s Dbs Side Effects

What Is The Risk Of Dbs Failure

10-15%

Few patients do not get any benefit after DBS. Proper selection of the DBS candidate helps to reduce this risk.

But, even if you dont improve initially after DBS surgery, there is still hope. A initial DBS failure can be converted into a success.

For example, the University of Florida & Harvard university studied patients who had not improved after DBS.

This study included both Parkinsons patients and some patients with other diseases.

The most common reasons for failure were:

• Incorrectly placed electrode.
• Incorrect DBS programming.
• Improper medication adjustment

With optimized care such as changing medication doses and reprogramming the DBS, more than half these patients improved.

Therefore the DBS risk of failure can be lowered.

In summary, DBS surgery risks are low. Deep Brain Stimulation side effects are uncommon, provided the evaluation is done carefully, BEFORE DBS.

Ont the other hand, the chances of DBS success are very high. They are described in another article.

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An Update On Best Practice Of Deep Brain Stimulation In Parkinsons Disease

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Dbs Appointments For Out

If you live outside the Portland area, we do everything we can to limit travel. We try to schedule appointments on the same day. In some cases, we offer appointments over a secure video connection from your local neurologists office. Your local neurologist can also help with some early and final appointments.

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How Deep Brain Stimulation Works

Exactly how DBS works is not completely understood, but many experts believe it regulates abnormal electrical signaling patterns in the brain. To control normal movement and other functions, brain cells communicate with each other using electrical signals. In Parkinsons disease, these signals become irregular and uncoordinated, which leads to motor symptoms. DBS may interrupt the irregular signaling patterns so cells can communicate more smoothly and symptoms lessen.

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

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Complications And Side Effects

Data regarding complications and side effects of deep brain stimulation for epilepsy is limited since it was only approved in 2018. However, it’s been used longer for managing Parkinson’s disease, and side effects are believed to be similar.

Adverse effects that have been noted in studies specific to deep brain stimulation for epilepsy include:

• Nerve pain or numbness from stimulation
• Pain at the implantation site
• Infection of the implantation site
• Bleeding around electrodes

Other possible complications observed with deep brain stimulation include:

• Wound infection

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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Dealing With Missing Data

We will use intention-to-treat data if provided by the trialists . We will, as the first option, contact all trial authors to obtain any relevant missing data , when individual patient data is not available.

Dichotomous outcome

We will not impute missing values for any outcomes in our primary analysis. In our sensitivity analyses , we will impute data.

Continuous outcomes

We will primarily analyse scores assessed at maximum follow-up. If only changes from baseline scores are reported, we will analyse the results together with follow-up scores . If standard deviations are not reported, we will calculate the SDs using relevant trial data , if possible. We will not use intention-to-treat data if the original report did not contain such data, per protocol data will then be used. In our bestworst-case and worst-best-case scenarios for continuous outcomes, we will impute data.

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.

Its important to keep in mind that while the above conditions might benefit from DBS, experts still dont 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.

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What Are The Advantages Of Deep Brain Stimulation

DBS has several advantages. These include:

• It can offer a treatment option when medications arent helpful: DBS is an option when medications don’t work or are no longer effective. With Parkinsons disease, medications lose effectiveness over time, so your healthcare provider has to increase your dosage. That leads to other side effects. With DBS, lower medication dosages are often effective again, which means your symptoms are under control with reduced side effects.
• It can be a life-changing treatment: Some of the conditions that DBS treats can cause severe effects that keep you from doing even the most routine activities. DBS can treat your condition and improve your symptoms, improving your overall quality of life. For conditions like medication-resistant epilepsy, where surgical resection isn’t an option, DBS can offer hope and reduction in seizure frequency.
• Its adjustable: Your healthcare provider can fine-tune the pulse generator settings to find what works best for you.
• Its reversible: A follow-up surgery can remove the leads and pulse generator if DBS doesn’t work or causes side effects that you can’t tolerate.

Conflict Of Interest Statement

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author has received grants for contributing to the development of stereotactic planning systems from Medtronic and Precisis.

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Governing Equation And Boundary Conditions

The distribution of the electric field in the vicinity of the electrode was calculated with the equation of continuity for steady currents. A trivial interpretation of the equation of continuity for steady currents is that the total amount of current within a region can only change by the amount that passes in or out of the boundary of the region. Thus, the total amount of current is preserved and cannot increase or decrease. For this reason, it can only move from one place to another.

In case of modeling the clinically relevant omnidirectional monopolar stimulation, the electrode configuration was simulated by setting the outer boundaries of the model to anode and the active electrode contacts to cathode. In order not to influence the results, the outer boundary needs to be located at a sufficient distance from the active electrode contacts. Simulations showed that already at a distance of 2 mm between the active electrode contact and the outer boundary the impact on the simulated electric field was negligible. For segmented electrodes, analogous modeling was used.

As already outlined above, FEMs were developed for simulations of the spatial distribution of the electric field. The distribution of the electric field in the vicinity of the electrode was calculated using the equation of continuity for steady currents:

where 2 is the Laplace operator.

Testing Before Deep Brain Stimulation

For patients with Parkinsons disease, the doctor must confirm that the PD is levodopa-responsive and determine which symptoms are most likely to respond to DBS and discuss these with the patient.

To accomplish these two objectives, the movement disorders neurologist will examine the patient in the absence of his or her PD medications, then again after having taken them. Seeing the effect of PD medications on the movement and non-motor symptoms helps the physician and patient identify good target symptoms for DBS.

A cognitive assessment can help determine a persons ability to participate in the procedure, which involves providing feedback to the doctor during surgery and throughout the neurostimulator adjustment process. This assessment also informs the team of the risk of having worsened confusion or cognitive problems following the procedure.

Some hospitals also perform an occupational therapy review or speech, language and swallowing assessment. A psychiatrist may examine the person to determine if a condition such as depression or anxiety requires treatment before the DBS procedure.

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Dealing With Patient’s Unrealistic Expectations

PD patients who undergo DBS have specific hopes and expectations regarding surgical outcome that are not limited solely to motor function improvement. In one study, out of 28 patients undergoing DBS-STN, 25% were disappointed with the outcome, 32% were indifferent, and only 43% perceived the result as positive. Higher apathy, depression, and axial symptom scores prior to DBS were shown to predict negative subjective perception of outcome., In addition, patients often overestimated daily activity function levels and underestimated present motor impairment prior to surgery, ultimately misinterpreting post procedural improvement magnitude. Kubu and coworkers identified significant lack of correlation between symptom goal severity ratings and standard clinical research metrics. Improvements in tremor, gait, non-motor symptoms, interpersonal relationships, work capacity, and vocational pursuits appeared more important to patients accepting to undergo DBS. In line with this, a prospective study of 21 patients receiving STN-DBS found occupational function, interpersonal relationships, and leisure activities did not improve after surgery. Patient expectations regarding professional life, activities of daily living, marital relations, and social adjustments were usually not appropriately met.-

What Happens During Surgery

For stage 1, implanting the electrodes in the brain, the entire process lasts 4 to 6 hours. The surgery generally lasts 3 to 4 hours.

Step 1: attach stereotactic frameThe procedure is performed stereotactically, which requires attaching a frame to your head. While you are seated, the frame is temporarily positioned on your head with Velcro straps. The four pin sites are injected with local anesthesia to minimize discomfort. You will feel some pressure as the pins are tightened .

Step 2: MRI or CT scanYou will then have an imaging scan, using either CT or MRI. A box-shaped localizing device is placed over the top of the frame. Markers in the box show up on the scan and help pinpoint the exact three-dimensional coordinates of the target area within the brain. The surgeon uses the MRI / CT scans and special computer software to plan the trajectory of the electrode.

Step 3: skin and skull incisionYou will be taken to the operating room. You will lie on the table and the stereotactic head frame will be secured. This prevents any small movements of your head while inserting the electrodes. You will remain awake during surgery. Light sedation is given to make you more comfortable during the initial skin incision, but then stopped so that you can talk to the doctors and perform tasks.

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In The Future If A Patients Disease Progresses They Can Be Exposed To Higher Stimulation Settings To Fight The Underlying Process And Not Experience Side Effects

A promising future for DBS

Each new technological advancement in DBS is helping us to explore how to further improve clinical outcomes for people suffering from movement disorders.

In addition to the reduction in side effects, Professor Lozano is excited about what this new technology potentially means for future battery generations and their application. If you use a shorter pulse width, then the total amount of energy you deliver is lower, so we can start thinking about even smaller batteries. Right now the batteries go in the chest if the batteries become small enough then we could put the batteries right next to the wires in the head. This means we could do the whole operation in one incision instead of two, making it much faster.

For Professor Fasano, this new technology means an expansion of the therapeutic window: Minimising side effects means you can expand the therapeutic window, meaning you can use more stimulation not just in the medium or short term but also in the long term. So in the future, if a patients disease progresses, they can be exposed to higher stimulation settings to fight the underlying process and not experience side effects.

Implantable pulse generators .

Does Dbs Have A Safety Profile

Medtronic DBS is a well-established therapy and many patients have benefited from it for 30 years.

In general, 8589% of people with Parkinsons have improvements with DBS therapy if people are carefully selected and the neurosurgeon places the lead correctly.1

As with any major surgery, there are some risks associated with the procedure, but these are very low when DBS is performed in specialised centres.2

For example, published studies show the following risks with Medtronic DBS systems:

• The risk of permanent health impairments is around 1.0%, mainly caused by bleeding within the skull.2
• As with other surgeries, death can occur. The risk of death is 0.4%.2. Although surgical procedures are different, total hip replacement, for example, has the same risk of death as DBS surgery.3.
• The risk of brain haemorrhage was 0% to 5% on average, in six high quality, multicentre studies conducted in different regions.4, 5, 6, 7, 8, 9
• The risk of infection from the device was 2.6% to 7.9% on average, in five high quality, multicentre studies conducted in different regions.2, 4, 7, 8, 9

When complications do occur in DBS, they are generally mild, short-lived and normally resolve around 30 to 90 days after surgery.7,10

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Deep Brain Stimulation For Parkinsons Disease

Deep brain stimulation is a surgical intervention used to treat movement disorders such as Parkinsons disease when the regimen of existing medications and the various rehabilitation strategies become less effective in managing symptoms. This surgical procedure received approval from the Food and Drug Administration to treat tremor in Parkinsons disease in July 1997 and for advanced motor symptoms of Parkinsons disease in January 2002.

For people with Parkinsons disease, deep brain stimulation surgery may be helpful if the individual is experiencing motor fluctuations including dyskinesias or off episodes.

The subthalamic nucleus and the globus pallidus are two locations in the brain that are targeted in the DBS procedure for Parkinsons. Certain symptoms of Parkinsons disease can be reduced when these two areas are turned off by the stimulator. These include tremor, rigidity, slowness of movement, difficulty walking, and freezing, as well as extra movements or dyskinesia that are medication side effects. The amount of daily on time during which the Parkinsons symptoms are better controlled can be increased as well.

The best marker of whether or not people with Parkinsons disease will benefit from DBS is how well they respond to levodopa, an active ingredient in the drug SinemetTM or carbidopa/levodopa. Patients who benefit most from surgery have had a good response to levodopa. For many, this good response becomes less and less as the disease progresses.

What Is The Risk Of Long

A few weeks after the surgery is done, the DBS current is switched on. Most people have marked relief from their Parkinsons symptoms at this time.

Many people do not have any Deep Brain Stimulation side effects.

But sometimes, the stimulation can cause some characteristic problems.

Deep Brain Stimulation side effects include possible worsening of 3 symptoms of Parkinsons disease:

• It can worsen Depression, if you already have uncontrollable depression.
• It can worsen Thinking & Memory problems, especially if you already have them.
• It can worsen falling, if your falling is caused mostly due to instability.

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