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Deep Brain Stimulation for Parkinson’s disease

Dr. Arif Dalvi March 24, 2009 12:00 PM This chat has ended. Thank you for participating.
Kristin (Moderator) - 11:59 AM:
Welcome! Today’s chat: Deep Brain Stimulation for Parkinson’s disease will begin shortly. Please start submitting your questions and Dr. Arif Dalvi will begin answering them as soon as we get started. While you are waiting for the chat to begin, feel free to visit the Parkinson’s Disease Section to obtain more information about Deep Brain Stimulation for Parkinson’s disease.

Dr. Arif Dalvi (NorthShore) - 12:00 PM:
Greetings. On behalf of the Parkinson's Disease and Movement Disorders Center at NorthShore University HealthSystem I would like to welcome you to this online chat. I hope it will be informative with regard to the role of surgery in Parkinson's disease. We will highlight the role of deep brain stimulation surgery in this area.

Aaron (Chicago) - 12:05 PM:
What qualifies a patient for DBS treatment?

Dr. Arif Dalvi (NorthShore):
In general there are a few broad indications for DBS. 1. A tremor that fails to respond adequately to medical treatment 2. Fluctuations in symptoms as is common in later stages of PD 3. Disabling involuntary movements called dyskinesias The patient should have a clearcut response to levodopa (Sinemet) or dopamine agonists in the early stages of PD, although the effect may be fluctuating or may be less predictable at the time surgery is being considered. Evaluation by a movement disorders specialist is required to rule out other conditions that may mimic Parkinson's disease.

Henry (Glenview) - 12:10 PM:
What is DBS?

Dr. Arif Dalvi (NorthShore):
DBS involves placing an electrode in the brain to deliver continuous high-frequency electrical stimulation to various parts of the brain that control movement. This stimulation is thought to suppress overactivity in areas of the brain that are affected by PD. The lay press calls it "a pacemaker for the brain" which is a useful description. Just like a pacemaker for the heart controls abnormal electrical activity in the heart, the DBS controls abnormal electrical activity in the brain. For example, when we map the brain to put in the DBS electrodes we may hear tremor cells firing in the brain. Once the DBS is turned on the firing of these tremor cells can be suppressed.

Aaron (Chicago) - 12:11 PM:
Are there other conditions that can be treated with DBS?

Dr. Arif Dalvi (NorthShore):
The FDA has approved DBS for Parkinson's disease and another tremor disorder called essential tremor(ET). The initial approval was in 1997 so this is not considered an experimental treatment for these conditions and we have over 10 years of experience with PD and essential tremor. In my experience we have also used DBS for dystonia, spasmodic torticollis (or cervical dystonia), and for tremor due to multiple sclerosis. There is some interest in this technique for Tourette syndrome, Huntington's chorea depression and epilepsy among others. However, except for PD and essential tremor all other indications are experimental.

Kurt Bloom (Gurnee, IL) - 12:14 PM:
I have a what my doctor called "Parkinsonism". The dexterity in my left hand is somewhat effected and now my right hand occasionally has a slight tremor also. I am a 61 year old male. The original dignosis was about 1 1/2 years ago. How long can I expect it to be before the symptoms become severe?

Dr. Arif Dalvi (NorthShore):
This is difficult to answer on an individual basis. As we learn more about PD, especially from the field of genetics, we realize that there is great individual variation. The early years of treatment are critical. Using medications in the correct order and giving preference to medicines with a potential for neuroprotective effect in the early stages, as opposed to pure symptom control, can considerably prolong quality of life.

Aaron (Chicago) - 12:17 PM:
Is DBS more successful than other Parkinson's surgeries?

Dr. Arif Dalvi (NorthShore):
The older techniques of pallidotomy and thalamotomy involve making a small stroke in the brain to suppress excessive activity. While they work well for a few years there is a tendency for symptoms to be back where they started in 3-4 years. The big advantage of DBS is that it is programmable. Just as we increase medications to keep pace with the disease, we can over time increase the DBS settings and continue to maintain good symptom control. The other advantage is that surgery on both sides of the brain is a lot safer with DBS than with the old lesioning techniques. Transplantation and gene therapy with surgical techniques are experimental strategies that are not yet ready for prime time.

Henry (Glenview) - 12:21 PM:
Is there a chance that the DBS implant could malfunction? If so, what happens? Is it dangerous?

Dr. Arif Dalvi (NorthShore):
The most common malfunction is spread of current from the area we want targetted to other areas. For example spread of current to centers that control speech can cause slurred speech instead of improving tremor. The huge advantage of DBS over pallidotomy is that we have 4 contact points on each DBS electrode (one on each side of the brain). If one of these contact points gives side effects we can chose one of the other three. In most cases we are able to find the "sweet spot" electrode that gives the best control of symptoms with the least side effects. Another rare malfunction is lead breakage. If this happens the DBS will lose effect and symptoms can come back. After about 3-5 years the battery wears off and symptoms return. replacing the battery is a relatively simple outpatient procedure. Infection can occur in about 5% of cases. Most often this can be treated with antibiotics but in some cases the DBS will need to be removed.

Aaron (Chicago) - 12:26 PM:
Is the procedure permanent? Or can the implant be removed if complications arise or another treatment becomes available?

Dr. Arif Dalvi (NorthShore):
While the battery life is typically 3-5 years, replacing the battery can be done as an outpatient. The implanted electrodes are not removed if symptom control has been good. In the case of infection the electrodes may be removed if not contolled by antibiotics. The electrode can be removed if alternatives become available, but this may not be necessary. It is conceivable, for example, that one could have DBS and stem cell implantation at the same time as the targets in the brain are different. This of course depends on the specific techniques that are developed in the future with reagrd to stem cells and similar surgeries.

Rex (Chicago) - 12:30 PM:
Is DBS treatment typically covered by insurance? What is the range of costs for a course of treatment involving DBS?

Dr. Arif Dalvi (NorthShore):
DBS has been approved by the FDA for the treatment of Parkinson's disease and essential tremor since 1997. As such, it is not experimental, and is covered by insurance including Medicare. Part of our review process before surgery includes a discussion of insurance issues.

Aaron (Chicago) - 12:32 PM:
Are there any complications associated with the DBS surgery?

Dr. Arif Dalvi (NorthShore):
The most restrictive complication is brain hemorrhage. As part of brain mapping or placing the DBS electrode a blood vessel may rupture and lead to bleeding in the brain. This happens in about 1-3% of patients. Some patients may have severe stroke-like symptoms as a result. Other complications include infection, and lead breakage which is very uncommon. Side effects from stimulation such as numbness, slurred speech, and double vision can occur, but can be minimized with skillful programming of the DBS device. Occasional patients may need repositioning of the DBS electrode if side effects limit response to treatment.

Aaron (Chicago) - 12:36 PM:
Will a patient still need to take medications after the procedure?

Dr. Arif Dalvi (NorthShore):
It is important to remember that DBS is not a cure for Parkinson's disease. Some patients may be able to reduce their dose by 20-30% but that is not the goal of surgery. The aim is to significantly improve symptom control and quality of life as opposed to reducing dosage or frequency of medications. With essential tremor there is a larger percentage of patients who are significantly able to reduce medication required for tremor conrol and some may completely stop taking any medications for tremor after DBS surgery.

Aaron (Chicago) - 12:39 PM:
Are there any factors that preclude a patient from this procedure?

Dr. Arif Dalvi (NorthShore):
When we offer patients DBS surgery we put them through a detailed screening process. A formal neuropsychological evaluation is performed in more cases to screen for significant dementia or depression. These may preclude surgery or require prior treatment before surgey is offered. Response to levodopa (even if not adequate) is improtant as we need to exclude atypical forms of Parkinsonism that do not respond well to DBS surgery. Age is not a contraindication in itself, and we have some patients who underwent DBS in their 80s. Most of our patients with DBS are younger than 75 as older patients tend to be less responsive.

Rex (Chicago) - 12:43 PM:
How many medical centers in the country are doing DBS treatment?

Dr. Arif Dalvi (NorthShore):
Given the success that pioneering centers such as NorthShore University Health Systems have had with DBS surgey it is natural that smaller centers have also started to offer this procedure. In general, this is a good thing. However, the learning curve is steep. Despite having participated in over 300 such procedures over the last 10 years I still find there are new things to learn as our knowledge becomes more sophisticated. It is important to remember that there is a huge team effort involved. In addition to a very skillful surgeon, the team should include a neurologist who specializes in movement disorders and has specific expertise in DBS. Our team here also includes a neurophysiologist and two PhDs that assist us in the brain mapping procedure. The fact that we have their extensive experience available in the operating room makes all the difference to acheiving a successful outcome.

Aaron (Chicago) - 12:48 PM:
Are patients completely sedated during the procedure or are they conscious?

Dr. Arif Dalvi (NorthShore):
For the first part of the surgery that involves brain mapping the patients are conscious or may have light sedation. It is interesting that the brain itself has no nerve endings and so we are able to map the brain with electrodes without the patients suffering any pain. The reason we need patients to be awake is that we listen for signalling patterns of the brain cells that allow us to target the overactive areas with accuracy. We are also able to look for improvements in tremor and speed of movement in the operating room and thus need our patients to be awake and cooperative.

Kristin (Moderator) - 12:50 PM:
Thank you everyone for your great participation, the chat will be ending in approximately 10 minutes. Please submit any final questions you have.

Henry (Glenview) - 12:51 PM:
I read that fridge magnets and anti-theft devices can interfere with the IPG, is this true?

Dr. Arif Dalvi (NorthShore):
Yes, although it is uncommon to have the DBS turned off as a result. We do ask patients when travelling through airport security to let the staff know thay have a DBS (pacemaker). Using the security wand does not turn the DBS off but walking thorough the security "doorway" may on occasion do this. We have patients with the DBS device who travel frequently without running into major issues. We do provide patients with an "Access Device" after surgery that allows them to turn it back on instantly if there is an accidental shutting off.

Rex (Chicago) - 12:54 PM:
How long is treatment and recovery before a patient goes home? What follow-up care is needed?

Dr. Arif Dalvi (NorthShore):
Most patients are in hospital for 2-3 days for the procedure. We do not turn the device on for about a month after surgery to allow the brain to heal and settle. Patients are back on their original medications until we turn the device on. The initial programming involves chosing the best contact points and finding the right settings. This may take 2-4 visits in general. We may reduce medications if symptoms are particularly well controlled. Once the proper settings are found we do ask patients to follow up initially every 2-3 months, although we can spread visits out to every 6 months or once a year in patients who are very stable. In general patients resume their normal level of activity and in many cases are able to increase it if good symptom control is acheived as expected.

Kristin (Moderator) - 12:58 PM:
Thank you again for participating in our chat today. For more information please visit our Parkinson’s Disease pages.


Dr. Arif Dalvi (NorthShore) - 1:00 PM:
Thank you all for the interesting questions. I hope this has helped to clarify the role of DBS surgery in Parkinson's disease and movement disorders. The team at the Movement Disorders Center at NorthShore University Health Systems is always available for specific evaluations for DBS surgery.
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