Life after Deep Brain Stimulation (DBS) or Brain Pacemakers for Advanced Parkinsons Disease

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.

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.

Deep Brain Stimulation (DBS) surgery is the only proven way out for such patients

1. 1. 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
   
   
   2. Tremor-Predominant Parkinsons Disease.


2.           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

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.

1. 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.
2. 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.
3. 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.
4. 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.
5. 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)
6. 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.
7. 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.
8. 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.

1. 30-60% Decrease in Dopaminergic medications (International average data).
   In Dr Sujoy Sanyal’s experience, 90% of his patients have been able to completely stop the main medicine called Levodopa altogether.


2. 80-90% Decrease in Drug-Induced Abnormal Movements or Dyskinesias (International data and Dr Sanyal’s long-term results are similar in this respect)


3. Average 6 hours increase in “GOOD ON” time, that is ON time without Abnormal Movements or Dyskinesias (International average data)
   In Dr Sujoy 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


4. Effective change in Quality of Life
   In Dr Sujoy 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


5. 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

1. 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.


2. 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.


3. Skillful post-operative DBS pacemaker programming along with Medical adjustment

1. 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.


2. 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.


3. 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.


4. 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.

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

1. Movement Disorders such as Dystonia and Essential Tremors uncontrolled by medications
2. Severe Obsessive Compulsive Disorder and Severe Depression