Deep Brain Stimulation for Parkinson's Disease Treatment in Turkey

Deep brain stimulation for Parkinson's disease

Learn about Parkinson's disease, its symptoms, causes, diagnosis, and the latest treatment methods for Parkinson's disease using deep brain stimulation to treat Parkinson's disease.

Parkinson's disease is a chronic, degenerative disease characterized by a gradual loss of neurons responsible for producing the neurotransmitter dopamine, resulting in problems with movement control and other symptoms not related to movement.

An overview of Parkinson's disease:

Parkinson's disease is a chronic, slowly progressive neurological disease that most commonly affects people over the age of 60. People with Parkinson's disease have difficulty controlling their body movements, and symptoms worsen as the condition progresses. Ultimately, Parkinson's disease impairs an individual's ability to act in everyday situations.

Parkinson's disease symptoms are caused by a loss of nerve cells in the brain responsible for controlling movement, and it also affects other areas, such as mood, sleep and thinking. The exact cause of neuronal loss is still unknown, but it is believed to involve a combination of genetic and environmental factors.

Parkinson's disease symptoms

Parkinson's disease is a progressive disorder, meaning that over time, new symptoms appear and slowly new symptoms become more severe. However, it is not an incurable disease - people can live for 15 to 25 years from the time of diagnosis - making it a long-term (chronic) condition.

Parkinson's disease symptoms can be categorized into motor and non-motor symptoms and complications.

  • Motor symptoms - the classic symptoms of Parkinson's disease - include tremor, slow movement, muscle stiffness and balance problems.
  • Non-motor symptoms - accompany all stages of Parkinson's disease and significantly affect the quality of life of patients, for example, sudden drop in blood pressure upon standing, mood disturbances, sleep disturbances, sensory problems, loss of sense of smell, constipation and impairment of cognitive abilities eg difficulties In memory, confusion and cases of dementia.
Parkinson's disease-symptoms
Parkinson's disease-symptoms

Complications

After several years of treatment, complications can begin to develop. These “complications” may include the alternation of the patient’s ability to control the disease as he goes through periods of good symptom control and poor symptom control at other times.

All these symptoms add significantly to the burden of disease.

Epidemiology and Burden of Parkinson's Disease

Parkinson's disease is one of the most common neurological disorders. It affected approximately 8.5 million men and women worldwide in 2017. The prevalence of Parkinson's disease in the United States will double by 2040 (compared to 2010). It affects men more than women.

Parkinson's disease usually develops in people in their late 50s and early 60s, although rare forms of the disease can appear before age 40. 1% of the population aged 60 or older has Parkinson's disease.

Because the risk of developing Parkinson's disease increases with age, the fact that more people are now living into old age means that the total number of people with Parkinson's disease is also rising.

Diagnosis and care

Parkinson's disease is diagnosed using a medical history, physical examination, and response to treatment. There is currently no reliable biochemical test, imaging, or genetic analysis that provides a definitive diagnosis. In addition, there are several evaluation criteria that can be used to determine disease symptoms and severity.

Currently, there is no cure for Parkinson's disease, but symptomatic treatments are available. Although current treatments for Parkinson's disease cannot stop the progression of the disease, they can temporarily control and relieve symptoms and improve quality of life for people with Parkinson's disease and their caregivers.

Treatment for Parkinson's disease usually includes drug therapy and, in some cases, surgery. In addition, physical exercise, diet, complementary therapies, and emotional and psychological support play an important role in improvement.

Deep Brain Stimulation for Parkinson's Disease Treatment in Turkey

What is deep brain stimulation to treat Parkinson's disease?

deep brain stimulation (DBS) It is a neurosurgical procedure that uses implanted electrodes and electrical stimulation to treat movement disorders associated with Parkinson's disease (PD), idiopathic tremor, dystonia and other neurological conditions.

Doctors may use deep brain stimulation for movement disorders or neuropsychiatric conditions when medications have become less effective or if their side effects interfere with a person's daily activities.

Drawing-illustration-of-deep-brain-stimulation-device-positioning
Drawing-illustration-of-deep-brain-stimulation-device-positioning

How does deep brain stimulation work to treat Parkinson's disease?

The motor symptoms of Parkinson's disease and other neurological conditions are caused by erratic electrical signals in the areas of the brain that control movement. When deep brain stimulation is successful, it interrupts the erratic signals that cause tremors and other movement symptoms.

After a series of tests that determine the optimal solution, neurosurgeons implant one or more wires into the brain. The wires are attached by an insulated wire extension to a very small nerve stimulator (electric generator) implanted under the collarbone, similar to a pacemaker. Continuous pulses of electrical current from the nerve stimulator pass through the wires and into the brain.

After a few weeks of running the neurostimulator, your doctor programmed it to deliver an electrical signal. This programming process may take more than one visit over the course of weeks or months to ensure that the amperage is adjusted properly and delivers effective results. When adjusting the device, the doctor strives to strike the optimal balance between improving symptom control and reducing side effects.

Who is the right person for deep brain stimulation?

Deep brain stimulation for Parkinson's disease is more than just a surgical procedure. It involves a series of assessments, procedures, and consultations before and after the actual operation, so people interested in dealing with DBS should be prepared to make time for the operation.

For example, those who don't live near a medical center that offers deep brain stimulation surgery may need to spend a significant amount of time traveling back and forth to appointments.

The procedure, as well as pre-operative evaluation and post-operative follow-up, can be expensive depending on the person's insurance coverage. Deep brain stimulation surgery is an FDA-approved treatment for Parkinson's disease, and most private insurance companies cover the procedure, but the extent of coverage will depend on each person's individual policy.

Patients who are suitable for the procedure should have realistic expectations about the results of DBS. Although deep brain stimulation can improve movement symptoms of Parkinson's disease and significantly improve quality of life in properly selected patients, it is unlikely to lead to a complete recovery.

Parkinson's patients with tremors

Three types of Parkinson's disease patients typically benefit from deep brain stimulation:

  • Patients with uncontrollable tremor for whom medication has not been effective.
  • Symptomatic patients respond well to medication but, when medication wears off, have severe motor fluctuations and dyskinesia, despite medication adjustments.
  • Patients whose movement symptoms may respond to higher or more frequent drug doses, but who are restricted in doing so due to side effects.

Parkinson's disease patients

A picture showing how a Parkinson's patient writes in a random line
How does a Parkinson's patient write on the left side of the picture?

Essential tremor is the most common movement disorder, and deep brain stimulation can be an effective treatment, especially in severe cases where shaking can disrupt daily tasks such as getting dressed, shaving, eating or drinking. Because shaking is the only symptom in idiopathic tremor, deep brain stimulation can improve the lives of people with this condition and help them function normally.

Patients with dystonia

Dystonia is a relatively uncommon movement disorder, but its symptoms — abnormal postures and twisting movements — can respond to deep brain stimulation when medications fail to provide adequate relief. An individual's response to DBS depends on the underlying cause of the dystonia—hereditary, drug-induced, or other factor. If the cause isn't known, your doctor will likely do more tests as part of a deep nerve stimulation exam.

Some psychological cases

Some recent studies have suggested that people with depression, obsessive-compulsive disorder (OCD), or Tourette's disorder may benefit from deep brain stimulation surgery. More research is needed to determine whether deep brain stimulation is effective in treating mental disorders and if any benefits outweigh the risks and side effects.

Choosing Deep Brain Stimulation Surgery

Deep brain stimulation surgery for Parkinson's disease isn't recommended for all people with Parkinson's disease or other movement disorders. Talking with a neurologist who specializes in movement disorders can determine if an individual is a good fit for deep brain stimulation.

When may a physician (or may not) opt for deep brain stimulation?

According to the National Parkinson's Foundation, a person with Parkinson's disease who is suitable for deep brain stimulation surgery to treat Parkinson's disease has:

  • Parkinson's symptoms that interfere with activities of daily living.
  • Movement fluctuations due to Parkinson's drugs with or without dyskinesia (involuntary trembling movements, especially in the arms and head).
  • Maintaining a good response to Parkinson's medication, even if the medication's effects may wear off sooner than in the past.
  • Use more than one Parkinson's medication under the supervision of a neurologist who specializes in movement disorders.

These factors may make a person less suitable for deep brain stimulation surgery:

  • Difficulty balancing, walking, or “freezing” as a major symptom of the disability.
  • One of the main symptoms is difficulty speaking.
  • Persistent confusion and problems with memory and thinking.
  • A mental condition such as depression or anxiety that has not improved or stabilized with other treatments.

Some of these factors can be treated. Having one or more doesn't rule out a person for future DBS surgery, but a doctor may recommend more aggressive treatment focused on these issues before surgery.

Close-up of the neurostimulator in place in the brain
This image shows where the Parkinson's battery is located in the brain

Testing before deep brain stimulation to treat Parkinson's disease

For patients with Parkinson's disease, the doctor must confirm that Parkinson's responds to levodopa (a drug combination that increases dopamine in the brain) and identify and discuss symptoms that are most likely to respond to DBS.

To achieve these two goals, the neurologist examines the patient with movement disorders when he or she is not taking his or her medications, and then again after taking them. Seeing the effect of Parkinson's medications on movement and non-motor symptoms helps the doctor and patient identify DBS target symptoms.

Cognitive assessment can help determine a person's ability to participate in the procedure, which includes providing feedback to the doctor during surgery and throughout the process of adjusting the neurostimulator. This assessment also informs the team of the risk of worsening confusion or cognitive problems after the procedure.

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

Deep brain stimulation procedure

In some cases, the surgeon inserts both the lead and the nerve stimulator together; In other cases, the two procedures can be performed separately, with the neurostimulator implanted days or weeks after the lead is placed.

Stereotactic deep brain stimulation vs. radiographic-guided interventional deep brain stimulation

Stereotactic deep brain stimulation surgery requires the patient to stop taking their medications. During the procedure, the frame stabilizes the head and provides coordinates to help surgeons direct the bullets to the correct location in the brain. The patient is given local anesthesia (numbing medicine) to keep them comfortable throughout each step and a mild sedative is given to help them relax.

During image-guided deep brain stimulation surgery, such as magnetic resonance imaging (MRI) or computed tomography, the patient is often under general anesthesia while the surgeon uses images of the brain to guide the patient to his or her target.

Some advanced centers offer both stereotaxic and fMRI-guided deep brain stimulation options for deep brain stimulation surgery. In this case, the doctor and patient will discuss the best procedure based on a number of factors.

For example, a doctor may recommend an image-guided procedure for children, patients with severe symptoms, or those who have particular anxiety or fear.

In general, deep brain stimulation surgery for Parkinson's disease follows this process:

1. Lead implantation:

The person removes clothing, jewelry, or other objects that may interfere with the procedure.

After shaving a small amount of hair behind the hairline, the surgical team injects a local anesthetic (numbing medication) into the scalp to position the head frame.

The head frame will be attached to the skull by screws, and remains in place during the entire procedure to keep the head in the correct position.

Next, the team uses CT or MRI scans to determine the target site in the brain where the lead will be implanted.

CT imaging during implantation of a pacemaker in Parkinson's patients
CT imaging during implantation of a pacemaker in Parkinson's patients

After giving an extra dose of narcotic medication, the neurosurgeon drills a small hole in the skull to insert the lead.

The team records the process as the bullets move through brain tissue to ensure accurate placement of the bullets. A person may be asked to move their face, arm, or leg at certain times during recordings.

Once the lead is in position, it is connected to an external nerve stimulator. Electrical stimulation given through the lead for a short time helps doctors see if symptoms improve or if side effects (eg muscle cramps or visual phenomena) appear.

An extension cord is attached to the lead and placed under the scalp, and the wire is attached to a neurostimulator.

The opening in the skull is closed with a plastic cap and stitches.

2. Microelectrode recording

Microelectrode recording (MER) uses electrical current (5-100uA) at a very high frequency (300Hz) to precisely locate the surgical site for a deep brain stimulator (DBS) implant. This technology was pioneered at Johns Hopkins University and has been approved by the American Academy of Neurology's Surgery Task Force on Parkinson's Disease and Therapeutic Evaluation and Technology Committee.

Because each person's brain structure is different, the information obtained from microelectrode recording gives an accurate target for the final DBS mode. Microelectrode recording allows the surgical team to visualize and hear neural activity from different areas of the brain to determine the exact location based on unique patterns of neural activity. The patient needs to be awake (not under general anesthesia) in order for the microelectrode recording program to provide high-quality information.

Radiograph showing the deep stimulation device used to treat Parkinson's disease
A radiograph showing the connection of the Parkinson's device and how it extends into the body

3. Neurostimulation mode

This operation is done under general anesthesia so that the person is asleep. The surgical team inserts the neurostimulator under the outer layers of skin, usually just below the collar bone, but sometimes in the chest or abdomen. An extension cord is connected to the neurostimulator.

How to perform deep brain stimulation to treat Parkinson's disease

After deep brain stimulation surgery

in the hospital

In general, the hospital stay after deep brain stimulation surgery for Parkinson's disease is 24 hours, but may be longer depending on how quickly the patient recovers and is ready to go home. The doctor will visit, make sure the person is ready to leave, and give instructions for home care.

at home

At home, it is important to keep wounds clean and dry. The doctor will provide the patient with details of how to shower while the surgical site is recovering. If there are stitches, they will be removed during your doctor's visit. The adhesive strips, if any, should be kept dry and will generally fall off within a few days.

The patient will be given a magnet that can be used to turn the neurostimulator on or off according to the conditions prescribed by the doctor.

Nervous stimulus programming

After the DBS wires for Parkinson's disease and the nerve stimulator are in place, the patient will return to the doctor for a neurostimulator programmed for optimal electrical stimulation. Programming generally begins a few weeks after the DBS procedure, although some doctors activate the neurostimulator before the patient is discharged from the hospital after surgery.

Programming takes time, and may require several appointments to adjust the settings of the neurostimulator. At the same time, doctors will monitor the patient's medications and doses so that the drugs work effectively with electrical stimulation to control symptoms.

Even after adjustment, the patient will need to return periodically for checkups. The doctor determines the frequency of follow-up appointments according to the specific situation of each patient.

The neurostimulator operates on a battery that generally lasts three to five years. When the battery begins to wear out, doctors can replace the neurostimulator in a simple outpatient procedure. There are also rechargeable neural stimuli that last longer, but require regular recharge.

Long-term effects of deep brain stimulation

Surgery can help Deep brain stimulation To treat Parkinson's disease, people with Parkinson's disease improve symptoms of tremor, stiffness, slowness, and dyskinesia. It can also reduce the dose of medication a patient needs to control Parkinson's.

Researchers who followed patients after DBS treatment for Parkinson's disease found that many patients continue to improve their symptoms for several years after the procedure and can eat, use the bathroom, and feed themselves. However, patients treated with deep brain stimulation for movement disorders may experience changes in memory, thinking, or mood.

Appear Study The patient's continuous improvement and good response to treatment ten years after the procedure.

At this time, Parkinson's disease is a progressive disorder that cannot be stopped completely. Even while DBS continues to act on tremors, rigidity, and slowness, other symptoms such as slurred speech, frozen walking, balance problems, and dementia may still appear.

Special precautions after deep brain stimulation

In general, people who have deep brain stimulation surgery to treat Parkinson's disease should:

  • Always carry an ID that states they have a DBS neurostimulator. In addition, they may want to wear a medical identification bracelet that indicates this information.
  • People with a neural stimulus should tell the airport security detectors before going through the detectors at the airport. Many airport detectors are safe for pacemakers, but a small amount of metal in a neurostimulator can trigger an alarm. Patients undergoing security screening with hand-held detectors should inform the security services that the detector wand should not be placed over the stimulus for longer than a few seconds, as these devices contain magnets that may affect the function or programming of the stimulus.
  • Patients with nerve wires and stimuli may not undergo some MRI procedures. Patients should always see their doctor before any type of MRI, although deep brain stimulation can be compatible with an MRI under certain circumstances. They should avoid places with large magnetic fields, such as power generators and auto junkyards that use large magnets.
  • Patients who have undergone deep brain stimulation surgery to treat Parkinson's disease should avoid exposure to heat in the a muscle therapy.
  • They should also avoid high voltage or radar machinery, such as radio or television transmitters, electric welding equipment, high tension wires, radar fixtures, or blast furnaces.
  • If patients are scheduled for surgery, they should tell their surgeon they have a neurostimulator ahead of time. It is important to seek advice on special precautions before and during surgery because equipment such as an electrical cautery device that controls bleeding may interfere with a neurostimulator.
  • When participating in a physical, recreational or sports activity, patients should protect the area of the nervous system from trauma.

Common Questions

No single direct cause of Parkinson's disease has been identified, and it is classified as a multifactorial disease, as there are many environmental and genetic factors that may cause it.

The answer varies depending on the patient's condition, the speed of symptoms and the age of onset of the disease, but in general he lives as a non-Parkinsonian counterpart, and complications may reduce life expectancy by a year or two.

Studies have reported that the average lifespan of a Parkinson's patient is approximately the same as a person without Parkinson's disease.

Symptoms of Parkinson's disease may appear in children and young adults, but the causes of it differ from Parkinson's disease in adults, it may appear as a result of some medications or metabolic disorders such as Wilson's disease.

Prices generally range between 15 and 35 thousand US dollars for both parties. As for the one party, it ranges between 12 and 20 thousand dollars.

The percentage of improvement in the patient's condition varies according to his condition, but it is not less than 50%.

So far, there have been no serious complications of this operation.

The success rate of Parkinson's surgery in Turkey is no less than 95 percent.

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