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Overview of Brain pacemaker
 

Overview of Brain pacemaker

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Deep brain stimulation (DBS)/Brain pacemaker has evolved as an important and established treatment modality for variety of advanced movement disorders and also for some psychiatry disorders.1Chronic ...

Deep brain stimulation (DBS)/Brain pacemaker has evolved as an important and established treatment modality for variety of advanced movement disorders and also for some psychiatry disorders.1Chronic DBS stimulation provides a non destructive and reversible means of disturbing the abnormal function of basal ganglia circuit. It can be adjusted as disease progresses or adverse event occur. Bilateral stimulation can be performed without a significant increase inadverse effects.Adverse events related to unintended stimulation of adjacent structures are readily reversible by altering the stimulus parameters.

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    Overview of Brain pacemaker Overview of Brain pacemaker Document Transcript

    • Overview of Brain pacemaker
    • a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 2 0 e2 2 2 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Review Article Overview of Brain pacemaker Sanjay Bhaumik Senior Consultant Neurologist, Apollo-Gleneagles Hospitals, 58 Canal Circular Road, Kolkata 700 054, West Bengal, India article info abstract Article history: Deep brain stimulation (DBS)/Brain pacemaker has evolved as an important and estab- Received 7 August 2013 lished treatment modality for variety of advanced movement disorders and also for some Accepted 8 August 2013 psychiatry disorders.1 Available online 6 September 2013 Chronic DBS stimulation provides a non destructive and reversible means of disturbing the abnormal function of basal ganglia circuit. It can be adjusted as disease progresses or Keywords: Pacing brain movement disorder adverse event occur. Bilateral stimulation can be performed without a significant increase in adverse effects. Deep brain stimulation (DBS) Adverse events related to unintended stimulation of adjacent structures are readily Parkinson’s disease reversible by altering the stimulus parameters. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Deep brain stimulation (DBS)/Brain pacemaker has evolved as an important and established treatment modality for variety of advanced movement disorders and also for some psychiatry disorders.1 Chronic DBS stimulation provides a non destructive and reversible means of disturbing the abnormal function of basal ganglia circuit. It can be adjusted as disease progresses or adverse event occur. Bilateral stimulation can be performed without a significant increase in adverse effects. Adverse events related to unintended stimulation of adjacent structures are readily reversible by altering the stimulus parameters. 2. What is a DBS device? It is an implantable device, made up of three main components: 1. Quadripolar brain electrodes 2. Pulse generator and 3. Extension wires The quadripolar leads are implanted into the region of brain involved with the disease process, using stereotactic neurosurgical technique. Current refinement of the knowledge of basal ganglia circuitry and pathophysiology of the diseases has narrowed the focus of movement disorder surgery to three key gray mater structures: 1. The thalamus 2. The globus pallidum and 3. The sub thalamic nucleus The lead implantation is usually performed in awake stage under local anesthesia to optimize the recoding of physiological data during the mapping procedures, as well as to elicit the patient’s repot of stimulus induced side effects. Pulse generator/Neuro stimulator is a small box shaped device that generates the electrical signals that are sent to the E-mail address: drsanjay_jogesh@hotmail.com. 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.08.014
    • a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 2 0 e2 2 2 electrodes. It is usually implanted under skin over subclavicular region. Extension wires are tunneled under the skin and connect the lead and pulse generator. After days or weeks of device implantation stimulation parameters are programmed. 3. How it works? Still there is no clearly described mechanism of action, though there are several likely possibilities.2 High frequency of stimulation may create a global hyperpolarisation of the cell membrane resulting loss of excitability. Stimulus may jam signal flow out of the abnormal functional areas. Although the mechanism of DBS is not yet worked out, doctors have enough experiences in using DBS to feel confident of its safety and effectiveness. 4. Where to consider DBS? There are currently three major movement disorders for which DBS is indicated: * Idiopathic Parkinson’s disease * Essential tremor and * Dystonia Many have touted the potential benefit of DBS in selected brain regions for variety of other disorders i.e. chronic pain, Tourette syndrome, depression and obsessive compulsive disorders. Still major indication remains for patient with Idiopathic Parkinson’s disease with significant disability inspite of optimizing medical therapy.3 5. When to consider DBS? The role of DBS is now viewed as a means of maintaining motor function before significant disability ensues-rather than being a last resort intervention for end stage Parkinson’s disease patient with no other treatment option. The goal is to be intervene, if possible when the patient reaches a stage where the daily burden motor symptomatology (motor fluctuation and dyskinesia) just begins to cause significant interference with daily function and occupational activities. Some surgical research protocols require that patient experiences a minimum amount (e.g. three to 4 h) of cumulative off and or dyskinesia time each day to justify DBS implant surgery. A number of factors need to be assessed in a systemic manner to determine each patient’s suitability for DBS treatment.4 Expectation of patient and relative should have realistic expectation regarding outcome after surgery. It is not a cure for PD. It improves the quality of life. It reduces tremor, rigidity, reduces motor fluctuation, increases on time and reduces dyskinesia. DBS will not have much effect on speech 221 difficulty, micrographia; sever postural instability, on time freezing of gait, dysautonomia and cognitive dysfunction. This treatment is effective only in idiopathic PD, not in other Parkinsonian syndromes. Needs proper identification of motor symptoms and signs which are most disabling and troublesome for the patient whether these are likely to improve by DBS. Needs proper optimization of pharmacological treatment. The degree to which a patient is responding to levodopa generally predicts the response after DBS. The mostly used scale to assess motor signs in patient with PD is the motor subscale (part III) of the UPDRS (Unified Parkinson’s disease rating scale). Many clinicians desire at least a 30% improvement of UPDRS score with Levodopa challenge. A clear understanding of patient’s cognitive function is important before DBS. Significant associated dementia suggests a widespread brain area involvement, a contraindication for DBS. Patient with significant dementia also will have difficulty in observing and articulating their symptoms, making adjustment of DBS parameters and medication difficult. To screen for dementia, a mini mental status examination (MMSE) and Mattis dementia rating scale (MDRS) can be performed. In general MMSE score of <¼24 and MDRS total score <¼130 is contraindication for DBS procedure.5 But there is no age limit to exclude if there are no signs of dementia or major psychiatric problem and are in good general health. 6. What are the risks and prognosis? The surgery required to implant a DBS device is expensive and potentially risky procedure, only recommended for selected patient. DBS is not a cure for PD. The patient must have realistic expectation regarding outcome of procedure. After DBS the requirement of medication reduces by 40e50% and quality of life improves by 60e70%.6 In India procedure costs between 7.5 to 9lac. Normally battery needs replacement after five years. Although DBS is generally recognized as a very safe procedure, any brain surgery carries some risks. Few common side effects are hemorrhage, infection, malfunctioning of electrodes, side effects of electric stimulation and at times mood changes. Fortunately all these side effects are usually temporary and can be managed easily. Conflicts of interest The author has none to declare. references 1. Tierney TS, Sankar T, Lozano AM. Deep brain stimulation emerging indications. Prog Brain Res. 2011;194:83e95. 2. Mcintyre CC, Savasta M, Kerkerian-Le Goff L, Vitek JL. Uncovering the mechanism(s) of action of deep brain stimulation: activation, inhibition, or both. Clin Neurophysiol. Jun 2004;115(6):239e248.
    • 222 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 2 0 e2 2 2 3. Weaver F, Follett K, Hur K, Ippolito D, Stern M. Deep brain stimulation in Parkinson disease; a metaanalysis of patient outcome. J Neurosurg. 2005;103:956e967. 4. Defer GL, Widner H, Marie RM, Remy P, Levivier M. Core assessment program for surgical interventional therapies in Parkinson’s disease (CAPSIT-PD). Mov Disord. 1999;14:572e584. 5. Saint-Cyr JA, Trepanier LL. Neuropsychologic assessment of patients for movement disorder surgery. Mov Disord. 2000;15:771e783. 6. Lang AE, Widner H. Deep brain stimulation for Parkinson’s disease: patient selection and evaluation. Mov Disord. 2002;17(suppl 3):S94eS101.
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