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What Is Deep Brain Stimulation (DBS)?

Loss of ability to control movement or loss of movement can manifest itself, if there is a damage in the area of the brain where specific brain cells responsible for movement control is located and/or due to insufficient production of neurotransmitters that take part in movement control. The most important surgical method used in treatment of neurologic disorders causing such damages is Deep Brain Stimulation. Deep Brain Stimulation is an adjustable and controllable surgical method, which effectively treats essential tremor disorders (uncontrolled tremor during voluntary movements), Parkinson’s disease and dystonia (involuntary contraction).

Deep Brain Stimulation provides perfect management of the neurological symptoms in these patients as the electrodes in the target area can be controlled without direct contact, and the system can be adjusted  until the symptoms of the patient disappear.  Deep Brain Stimulation surgery use advanced technology and is less risky compared to other neurosurgeries. Deep Brain Stimulation improves life quality and enables especially Parkinsons patients to maintain normal daily lives.

Which Diseases Benefit from Deep Brain Stimulation ?

Deep Brain Stimulation is used to minimize symptoms of certain diseases.
•    Parkinson’s disease,
•    Epilepsy,
•    Trembling in some parts of body (Essential Tremor),
•    Involuntary contraction disorders in certain body parts (Dystonia),
•    Twitching disorders (Tourette syndrome),
•    Obsessive and compulsive disorders,
•    Major depression.
Currently use of Deep Brain Stimulation in Alzheimer’s disease and obesity (overweight) is under development. 

What Are The Results?

Patients can resume their normal lives very shortly  after Deep Brain Stimulation Surgery.  Daily lives of patients improve after the surgery especially those with Parkinson’s disease and those with involuntary contractions. Those patients who suffer from tremor attacks and excessive muscle contractions, those who don’t have total control of their movements also benefit from Deep Brain Stimulation surgery as they can return to the early stages of their diseases. After Deep Brain Stimulation surgery,  daily medication use is reduced and some patients can stop using medication altogether.

Although Deep Brain Stimulation provides relief from symptoms, it does not cure underlying disease. Neurologic diseases are usually caused by damages to certain parts of brain. Deep Brain Stimulation can not repair the damaged regions however it diminishes the symptoms due to the malfunction  of  the affected area. Therefore complaints such as such as tremors, inability to control movements and slow movements improve.

Especially in patients with Parkinson’s disease, reduction of symptoms to a minimum level is possible with Deep Brain Stimulation.  In individuals at advanced stages of Parkinson’s disease, those who have had the disease for 10 years,  Deep Brain Stimulation reverses the disease to the early stages of Parkinson’s. Those who were unable to perform simple daily tasks as buttoning up a shirt, preparing food or doing their shoe laces and those were detached from social life  can lead a normal independent lives without needing help.

How Is Deep Brain Stimulation Surgery Performed?

The aim of Deep Brain Stimulation is to provide regular electric stimulation to the damaged region of the brain where there is dysfunction of electrical activity. Before the operation, damaged brain region is identified by brain mapping using MRI and other imaging technologies. Guided by the brain map of the patient,  the effected region where the electrodes should be placed is defined and thin wires to provide electrical activity for these regions are implanted. A neurostimulator ( brain pacemaker) is implanted below the collar bone or to the chest wall to deliver the electrical stimulation to the brain.

Based on the framework of the Deep Brain Stimulation Surgery explained above, there are also certain procedures to follow before, during and after the operation. 
Preoperative Procedures

Certain tests must be performed to determine patients’ condition before the surgery. Magnetic Resonance and Computerized Tomography  imaging of brain are main technologies used for brain mapping. 

Patients are assessed by an anesthesiologist to determine their suitability for anesthesia and to decide which type of anesthesia should be administered.
Blood and urine tests are performed to assess patient’s general health . Some of these tests are total blood count, blood chemistry, hormone tests, renal function tests others if needed. 
Deep Brain Stimulation surgeries affect not only the physical but also psychological status of the patients. Psychiatric consultations are organized as part of surgery preparedness if necessary.

A full history of the patient including medications used plus the blood tests and investigations discussed above, patient is ready for the operation. 

Surgery

Deep Brain Stimulation surgeries can be performed while patient is awake or under anesthesia. This depends on the disease and physician’s decision. In awake surgery, surgeons make a small hole under local anesthesia and  place the electrodes to the locations pre-determined by the brain map. Although patients are conscious during the procedure while electrodes are being adjusted, they do not feel pain. The neurostimulator (brain pacemaker) is implanted under the skin, generally in chest wall. Therefore, general anesthesia is applied to prevent feeling of pain during the surgery.           

In surgeries performed under general anesthesia, placement of electrodes in the target and inplantation of the stimulator are performed in the same session.
Deep Brain stimulation surgery carries a very low risk compared to other brain surgeries. Operation takes 2 to 5 hours on average but this can vary between the patients.

Postoperative Procedures

Patients are admitted to hospital to monitor the possibility of complications after surgery on the first day. Headache is a common and expected complaint after the surgery  which can be accompanied by dizziness. If these temporary complaints are unusually severe, medical intervention may be necessisated.
Although the surgery is a low risk one, complications and side effects can be seen as is the case with all surgeries. Possible complications include vascular occlusions, infections, bleedings, visual disorders, balance disorders and nerve damages.
What Are The Risks of Deep Brain Stimulation Surgery?
Deep Brain Stimulation surgeries have proven to be less risky of all neurosurgical operations. However, like any surgery, it is not total risk free. Studies have reported serious complications in 2 to 3  % of patients who had Deep Brain Stimulation surgery. Minor complications are seen in approximately 10% of patients.
Some complications of Deep Brain Stimulation surgery are as follows:
•    Cerebral hemorrhages,
•    Wound related problems,
•    Loss of vision, 
•    Hardware complications, such as an eroded lead wire. 
•    Infection 
•    Contact disorders.

Frequently Asked Questions

Does Deep Brain Stimulation Affect Daily Life?

Deep Brain Stimulation reverses the symptoms of certain diseases and it does not bring an extra burden to daily life. Patients with Deep Brain Stimulators can maintain their daily lives in a way healthy individuals do.

How long does it last?

Deep Brain Stimulators are like batteris and have a certain expiration date. Deep Brain Stimulators used in different diseases have different life spans. Deep Brain Stimulators used in Parkinson’s disease usually last between 3 to 5 years, where as those used in dystonia require a different application and have shorter lives. Rechargeable Deep Brain Stimulators can be used for more than 5 years and can be expected to last for about 15 years.

Can patients with Deep Brain Stimulators do physical activities?

Yes. Patients with Deep Brain stimulators can do all sorts of physical activities such as regular physical exercises and other sports activities such as swimming, football and tennis. However extreme sports and driving must be avoided to prevent accidental head traumas.

Who are not suitable for Deep Brain Stimulation?

Eligibility for Deep Brain Surgery depends on meeting certain criteria. Deep Brain Stimulation is not a prefered treatment in the early stages, especially first five years of Parkinsons Disease if it is controlled well with medical treatment.  Deep Brain Stimulation must be avoided in patients who have moderate or advanced dementia, severe depressive attacks and if there are contraindications for general anesthesia.

Is there an infection risk following Deep Brain Stimulation Surgery?

Studies report 3% infection rate following surgery usually in the thoracic region where the power source is placed.
Are radiologic imaging investigations safe for patients with Deep Brain Stimulators ?
Brain imaging technologies such as MRI and CTI as well as  x-rays do not affect the patients with Deep Brain Stimulators. However, body imaging with MRI device is not recommended for these patients.

If the deep Brain Stimulator is not re-charged, can it be used again?

This depends on the model of Deep Brain stimulator while it is possible to recharge most of the rechargeable models after turning off.

How long does it take to recover after Deep Brain Surgery?

Recovery period is 1 month on average, including a couple of days after the operation under medical observation, dressing of the wounds and removal of stitches on day 10-14 post operatively. This period can prolong in case of complications such as persisting side effects.

Does Deep Brain Stimulation cure the disease?

No. Deep Brain stimulation minimizes the symptoms of diseases characterized with involuntary movements such as Parkinson’s disease and dystonia. Being symptom free is only possible if the Deep Brain Stimulator is used. This means that symptoms will come back when Deep Brain Stimulator is not used.

 

 

Medicana International Samsun, 

Neurosurgeon Assoc. Prof. Enis Kuruoğlu, M.D.

 

 

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