What is Deep Brain Stimulation Surgery?

Deep brain stimulation (DBS) surgery (sometimes referred to as a "brain pacemaker") is a technological surgical procedure involving the placement of two electrodes inside the brain and connect them via extension cables to a neurostimulator (pulse generator). This implantable pulse generator sends electrical impulses, through implanted electrodes, to specific targets in the brain (brain nuclei) for the treatment of some disorders including Parkinson's disease, essential tremor, dystonia, Obsessive Compulsive Disorder (OCD), and Epilepsy.

How is deep brain stimulation surgery performed?

Deep brain stimulation (DBS) surgery is performed in two parts. 

In first part we need to implant two bilateral electrodes inside the brain nuclei (which targeted area by MRI images before) via two small holes under local or general anesthesia. In this part of the surgery the patient doesn't feel any pain because of the local anesthesia.

When we are implanting the electrodes we do a micro electrode recording (listening the sound of the brain) to evaluate the areas of the brain and to be sure to implant the electrodes in correct position. After the implantation we send a test signals to evaluate the position of the electrodes and we evaluate the patient's symptomes (is the tremor stopped? or is the rigidity resolved?) We can change the position of the electrodes by this evaluation if it's necessary. When the surgical team satisfied about the Micro electrode recording and Macrostimulation results we can pass to the second stage.

In second stage we need to implant the Implantable Pulse Generator (battery) under the skin on subclavicle area and connect it to electrodes by extension wires. In this stage we need to take the patient under general anesthesia.

Who's candidate for Deep Brain Stimulation surgery?

Deep Brain Stimulation surgery (brain pacemaker surgery) can use for the following disorders:

• Parkinson's disease:
• Essential tremor:
• Dystonia:
• Obsessive Compulsive Disorder
• Epilepsy

Who's candidate for Deep Brain Stimulation in Parkinson's Disease?

• Clear diagnosis of idiopathic (arising spontaneously)
• Parkinson's disease 
• Absence of dementia
• Any fluctuations in symptoms with levodopa therapy (Parcopa, Sinemet, Stalevo)
• At least some improvement with levodopa therapy
• Lack of serious disease preventing surgery
• No age parameters, but patients under 75 generally do better

Who's candidate for Deep Brain Stimulation in Dystonia?

In general the best dystonia (a twisting disease where agonist and antagonist muscles co contract and leave the sufferer in abnormal postures which may be worsened by action) surgical candidates suffer from generalized disease (multiple body regions) which may or may not be the result of an identified genetic defect. This criteria is a generality based on a limited experience, however as more reports of DBS for focal dystonia emerge, the criteria may be expanded. Secondary dystonia, or dystonia due to other causes such as trauma, toxin, birth defect, or metabolic disorder seems to be less responsive to DBS, although the best surgical target remains to be defined for these cases, and there has been some successes reported.

Who's candidate for Deep Brain Stimulation in Essential Tremor?

ET candidates for DBS must have medication refractory tremor defined as having failed maximal titrations and preferably combinations of a beta blocker, primidone, and possibly a benzodiazepine. There are other medications that have been found effective in some patients with ET and these may be tried as well.

What is the best indicator for surgery?

Especially in Parkinson's disease, the levodopa response is so important. If the patient's response to levodopa treatment is positive, it means that he/her will benefit from Deep Brain

Stimulation surgery. If the medications are inadequate to suppress the symptoms or began to cause side effects, the patient must be have Deep Brain Stimulation surgery.

What are the advantages of brain pacemaker surgery?

• Reversibility: The system doesn't result with permanent damage. The stimulation can be turned off by remote control

• Adjustable :The stimulation settings can be adjust by a remote control.

• Rechargeable: There is a rechargeable Implantable pulse generator option.

• Proven as more effective and safer than ablative approaches. Long-term complications are fewer than with traditional surgery because traditional surgery involves destroying small parts of the brain, while DBS does not.

What are the risks for Deep Brain Stimulation surgery?

You need to remember there isn't any surgery without risk.

General complications of any surgeries are bleeding, infection, blood clots, and reactions to anesthesia. Since the Deep Brain Stimulation surgery does only from two bur-hole Complications of the Deep Brain Stimulation surgery is very low. But the experience of the whole surgery team is so important like all surgeries.

DBS may also cause worsening of some symptoms in some patients such as speech and balance impairments. In that point the evaluation of the patient before the surgery by an experienced team is crucial. Our team has experience more than 300 surgeries and include Neurosurgeon, Neurologist, Programmer Physician, Physical Therapy and Rehabilitation physician and technicians and Neuropsychiatrist.

Among the risks of DBS surgery, we can list the following in general:

• Infection risk: The standart peroperative and postoperative antibiotic administration is crucial.

• Bleeding Risk: It can prevented by careful trajectory evaluation. We always use contrast enhanced MRI to evaluate all vascular structures.

• Hardware complications: There is a chance the lead may migrate, or the electrode, Connecting wire, or impulse generator may break and need e replaced.

What are the Contraindications?

• Parkinson Plus diseases
• Dementia
• Active psychiatric disorders
• Dominant levodopa-resistant motor symptoms
• Active infection

By RECMED MEDICAL - BRAIN AND NERVE SURGERY DOCTORS