Maximising increase in ON time to 24 Hours GOOD ON and Decrease in Dopaminergic Drugs to Complete Levodopa stoppage following Brain Pacemaker or Deep Brain Stimulation (DBS) surgery for Advanced Parkinsons Disease using Constant Current Technology : Calcutta in Eastern India leads the way
Symptoms of Typical Parkinsons’ Disease:
Slowness of movement
Tremor
Rigidity/Stiffness of all limbs
May initially start on one side and then involve the other side
Symptoms will initially respond well to medicines, especially Levodopa
Initial response to medicines is almost a diagnostic hallmark of Typical Parkinsons Disease
Tremors may not respond to medicines even in the beginning
Parkinsons Disease however is a progressive illness.
What is Advanced Parkinsons’ Disease:
Symptoms of Parkinsons Disease (slowness of movement, rigidity, tremor) continue to increase over the years and along with that increases the requirement of medicines along with the side-effects of medicines.
Finally, the symptoms increase to such a degree that even on high doses of medications at frequent intervals, patients have insignificant relief.
After taking medicines, they get very short-lasting relief (ON) which may or may not be accompanied by drug-induced abnormal movements.
Thereafter, they again become slow/ stiff/tremulous and incapacitated. This state is medically described as an “OFF” state.
They may need help for all their activities of daily living.
Treatment of Advanced Parkinsons’ Disease:
Medicines have nothing more to offer when patients reach the above-mentioned advanced stage of Parkinsons’ Disease.
Deep Brain Stimulation (DBS) surgery is the only proven way out for such patients
Who is eligible and who is a good candidate and who qualifies for DBS/Deep Brain Stimulation (Brain Pacemaker) in Advanced Parkinsons’ Disease:
Patients with Advanced Typical Parkinsons Disease with ON-OFF and/or Levodopa-induced Dyskinesias or abnormal movements. Pre-requisite for DBS: Sustained ON response to Levodopa albeit short
Tremor-Predominant Parkinsons Disease.
Important criteria to consider before recommending DBS Absence of Dementia/Active Psychiatric disease Disease duration of at least 5 years No other major medical illnesses precluding surgery
Window of opportunity for DBS in Advanced Parkinsons’ Disease:
An International Trial has proven that the earlier DBS is done for Advanced Parkinsons Disease, the better is the long-term outcome (New England Journal of Medicine February 2014)
Parkinsons Disease is a progressive illness. If DBS is not done in time, the disease will progress to an inoperable stage.
What is Deep Brain Stimulation (DBS) surgery or Brain Pacemaker surgery:
Computer-guided exact placement of 2 electrical leads at a deep nucleus inside the brain on both sides, called the Subthalamic Nucleus, which measures around 5 mm.
The leads are placed through 2 small holes made on either side of the skull.
The electrodes are thereafter tunneled under the skin and connected to a pacemaker placed just below the collarbone underneath the skin. The pacemaker stimulates the Subthalamic Nucleus on both sides through the electrical leads. That is why, it is called a Brain Pacemaker. Nothing can be seen from the outside.
How is Deep Brain Stimulation (DBS) surgery or Brain Pacemaker surgery done
The patient undergoes a 3-T MRI with a special protocol 2 days prior to surgery. The MRI is used to identify a deep nucleus in the brain on both sides, called the Subthalamic Nucleus, which measures around 5 mm.
On the morning of surgery, a frame with a square box is fixed to the patient’s head with four pins under local anaesthesia. This frame is called a Stereotactic Frame because it has XYZ coordinates along the Vertical, Horizontal and Anteroposterior axes. Thereafter, the patient undergoes a CT scan with the frame in place. After CT scan with a Stereotactic Frame on the head, any point in the brain can be assigned a XYZ coordinate.
The next step is on a surgical planning station where Dr Sanyal sits down with the CT scan and the pre-operative MRI scan. He uses the MRI to identify a deep nucleus in the brain on both sides, called the Subthalamic Nucleus, which measures around 5 mm. He thereafter fuses the pre-operative MRI (on which the Subthalamic Nucleus has been identified on both sides) to the CT scan with the Stereotactic Frame. He thus identifies the XYZ coordinates of the Subthalamic Nucleus on both sides.
The action hereafter shifts to the Operating Room. Two small holes are made sequentially on either side of the skull and 5 hair-thin microelectrodes are driven to the XYZ coordinates and 2 mm around in 4 directions sequentially on both sides. The hair-thin microelectrodes are used to record from the cells in the brain through which they pass. Confirmation is made that the microelectrodes have indeed reached the Subthalamic Nucleus on both sides by identifying the characteristic firing rate of the neurons in this nucleus.
Re-confirmation that the electrodes have indeed reached the Subthalamic Nucleus is made by stimulating the electrodes and seeing whether stimulation decreases the stiffness/slowness/tremor of the arms and legs (medicines are stopped the night before surgery to ensure that the patient is stiff/slow/tremulous during surgery in order to evaluate the effect of intraoperative stimulation)
Needless to say, this means that the patient remains awake all through the surgery because he is asked to move his limbs to see whether his stiffness/slowness/tremor is responding to stimulation.
Even small displacements of the final lead from the intended position can lead to a sub-optimal result. Larger displacements may require re-surgery. Therefore, for optimal results, it is best to lock the lead in place by a locking cap.
Once the electrodes have been locked in place in the best part of the Subthalamic Nucleus determined by Microelectrode recording and Inraoperative response to stimulation , the patient is put under anaesthesia, the steretotactic frame is removed, and the electrodes are tunneled underneath the skin before being finally connected to a pacemaker placed just below the collarbone.
Long-term Benefits or outcomes or advantages of Deep Brain Stimulation (DBS) or Brain Pacemakers for Advanced Parkinsons Disease (International data vis-a-vis Dr Sanyal’s long-term experience)
30-60% Decrease in Dopaminergic medications (International average data)
In Dr Sanyal’s experience, 90% of his patients have been able to completely stop the main medicine called Levodopa altogether.
80-90% Decrease in Drug-Induced Abnormal Movements or Dyskinesias(International data and Dr Sanyal’s long-term results are similar in this respect)
Average 6 hours increase in “GOOD ON” time, that is ON time without Abnormal Movements or Dyskinesias (International average data)
In Dr Sanyal’s experience, almost all his patients are GOOD ON without Abnormal Movements or Dyskinesias for 24 hours a day, which almost makes them similar to any other normal human being
Significant change in Quality of Life
In Dr Sanyal’s experience, patients totally disabled and on the verge of voluntary retirement have gone back to work, homemakers totally dependent on caregivers are back to cooking and even stitching/sewing
DBS surgery is extremely successful in Tremor-predominant Parkinsons’ Disease who suffer mainly from Tremors and may not respond to medications right from the beginning
How is life after Deep Brain Stimulation (DBS) surgery or Brain Pacemakers for Advanced Parkinsons Disease (International data vis-a-vis Dr Sanyal’s long-term experience)
Prior to DBS Surgery, patients of Advanced Parkinsons are “ON” for only a short time following every dose of medication sometimes accompanied by severe medication-induced uncontrollable involuntary movements. The rest of the time they are “OFF”/ stiff, slow, tremulous.
Following Deep Brain Stimulation (DBS) or Brain Pacemaker surgery, the average International data says that severe uncontrollable involuntary movements decrease significantly and patients have significant increase in GOOD ON time without drug-induced abnormal movements while they are also able to decrease their Dopaminergic medications somewhat.
Dr Sujoy Sanyal’s patients improve remarkably in the sense that they are ON for 24 hours a day without drug-induced abnormal movements and 90% of them are actually able to stop Levodopa completely. This is evidently a life-changing improvement.
Why is Levodopa decrease/stoppage important
Psychological benefit.
DBS does not really affect Parkinsons Disease progression
Thereby, the lesser the current and the lesser the drugs post-operatively the more the ammunition in store for the future.
Levodopa is associated with ON-OFF (when the drug starts acting, the patient becomes ON; when the action of the drug wears off, the patient becomes OFF)
Levodopa is directly responsible for Drug-Induced Dyskinesias
Post-operative stoppage of Levodopa and use of Only current (which works the same for 24 hours) and if necessary dopamine agonist such as Pramipexole (which leads to much more constant drug levels in the blood round the clock compared to Levodopa) likely to give smoother results thus resulting in the disappearance of ON-OFF (resulting in 24 Hours ON) and elimination of drug-induced Dyskinesias.
Keys to success in Deep Brain Stimulation (DBS) surgery or Brain Pacemaker surgery for Advanced Parkinsons Disease
Proper Patient Selection and adequate Pre-operative Counselling: Patients of Advanced Parkinsons Disease with ON-OFF and/or drug-induced abnormal movements with no significant problems in memory and intelligence and no significant psychiatric issues make good candidates for DBS surgery.
Precise placement of leads and pacemaker which comes from precision at each and every step of this multi-step surgery. Dr Sujoy Sanyal is actively involved at every step of this surgery which commences from the pre-operative MRI and ends with the last suture. Dr Sanyal believes in the age-old proverb “Too many cooks spoil the broth” and therefore personally takes care of every step of the surgery.
Skillful post-operative DBS pacemaker programming along with Medical adjustment
Skillful post-operative DBS pacemaker programming and Medical adjustment:
Is the last key to success but an equally important key Each lead has 4 contacts, each of which can be set to off, positive or negative. The voltage, current, pulse-width and frequency of stimulation can be set within large limits on both sides Pacemaker programming is done by using a remote.
In the initial couple of months following surgery, pacemaker programming and medicine adjustment may have to be done frequently which might require repeated visits to the operating doctor. Later, pacemaker programming and medicine adjustment may need to be done at 3-6 months intervals.
With the advent of video-transfer apps such as Whats app/Viber/Telegram on smartphones, outstation patients follow-up by sending videos to Dr Sujoy Sanyal who advises changes in current, if necessary, within preset limits or changes in medication based on problems identified on the videos. These minor changes in current can be made by the patient’s relatives or friends using a small patient remote. However, for further fine-tuning and for addressal of problems not solved by current changes done using the patient remote, the patient has to visit Dr Sanyal wherein the programming is done by a stronger clinician programmer. The requirement for this is actually very rare after the first 2 months.
Dr Sanyal has patients as far as Mauritius (who actually opted to undergo surgery under Dr Sanyal at Calcutta, India after having visited Paris) who follow up with him completely on Whats app/Viber/Telegram.
Advanced Technology: Rechargeable Pacemakers for Deep Brain Stimulation (DBS) for Advanced Parkinsons Disease
Previous generation non-rechargeable pacemakers required to be changed by an expensive operation every 3-5 years once the battery got exhausted
Dr Sujoy Sanyal pioneered Rechargeable Brain Pacemakers in India way back in 2010
Rechargeable pacemakers can be re-charged just by placing an antenna on the surface of the skin below which the pacemaker is implanted and connecting the antenna to a charged power source, while the patient watches television or relaxes
Rechargeable pacemakers can last at least 15 years approximately without having to change it by an expensive operation
Other indications of Deep Brain Stimulation(DBS) or Brain Pacemakers
Movement Disorders such as Dystonia and Essential Tremors uncontrolled by medications
Severe Obsessive Compulsive Disorder and Severe Depression
Spine Pacemakers
Spinal Cord Pacemakers are used for Urinary Urge Incontinence, Non-Obstructive Urinary Retention and Chronic Faecal Incontinence.
Dr Sujoy K Sanyal’s Brain Pacemaker (DBS) Program
Runs one of the world’s most successful Brain Pacemaker Programs
Attributes his success to the fact that he runs a one-stop shop. Most DBS programs all over the world are multidisciplinary programs which means a Neurologist takes care of the medications and selects patients for surgery and also does the medical followup after surgery while a radiologist does the MRI, a Neurosurgeon does the main surgery, a junior Neurosurgeon does the rest of the surgery, an Intensivist takes post-operative care while often the pacemaker programming is left to technicians. Dr Sanyal in contrast takes care of everything from selecting and counselling patients to getting the MRI done to preoperative software surgical planning to surgery right from incision to the last suture to leading the post-operative care team till discharge to taking care of post-operative pacemaker programming and medical adjustment of the patient for life. Obviously, he is ably assisted at each stage but he does not believe in leaving anything to any other person because Dr Sanyals belief is that no one can and no one will take care of his patients like him because the emotional connect to the patient may be missing.
Another reason he attributes to his success is his belief in precise copy-book surgery. He gets the MRI done himself on which the Subthalamic Nucleus is identified, does not compromise on preoperative software planning, intraoperative microelectrode recording using 5 microelectrodes, intraoperative macrostimulation testing and does not sacrifice precision at the altar of speed.
Pioneered Rechargeable Brain Pacemakers in India way back in 2010
Pioneer in Eastern India of DBS for Advanced Parkinsons Disease/Tremors/Dystonia
Successfully performed DBS for a 78 year old lady, one of the oldest in the world to have undergone this surgery.
Has harnessed the power of video-messaging apps such as Whatsapp/Viver/Telegram for follow-up and pacemaker programming/medical adjustment for patients located as far from Calcutta, India as Mauritius.
Invited Faculty on Deep Brain Stimulation (Maximising Decrease in Dopaminergic Drug Dosage and Increase in GOOD ON time Following Bilateral STN DBS Using Constant Current for Advanced Parkinsons Disease)
World Federation of Neurosurgical Societies (Special Congress), Beijing, China, 2019
World Congress of Neurosurgeons, Istanbul, Turkey, 2017
World Congress of Neurosurgeons, Seoul, South Korea, 2013
2nd International Fujita Bantane Interim Meeting of Neurosurgery, Bali,Indonesia, 2018
Asian Congress of Neurosurgeons, Astana, Kazakhstan 2014
5th International Congress on Minimally Invasive Neurosurgery, Phuket, Thailand, 2019
