Deep Brain Stimulation

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What is deep brain stimulation?

Deep brain stimulation (DBS) is a surgical option for patients with Parkinson’s disease, essential tremor, dystonia, tremor due to multiple sclerosis, OCD and depression. During DBS surgery electrodes are implanted within the brain to deliver electrical impulses. DBS offers patients relief from the tremors, rigidity, slowness of movement, stiffness and may help balance problems associated with their conditions. The stimulation can be adjusted as the patient’s condition changes over time.

DBS is a new and improved variation of an old surgery. The old surgery involved destroying small parts of the brain within structures called the thalamus, or globus pallidus. Today, it is no longer necessary to destroy even small parts of the brain with DBS.

How does deep brain stimulation work?

An electrode implanted in the brain emits pulses of energy to block the abnormal activity in the brain which causes the symptoms of movement disorders like dystonia. The success of DBS surgery is directly related to finding the specific area in the brain for stimulation.

Who is a candidate for deep brain stimulation surgery?

  • Any patient who is not satisfied with his/her increasing loss of control of movement that arises from dystonia or other movement disorders
  • Exhibits symptoms causing a decline in the quality of life
  • Has had an adequate and reasonable trial of medications

How is deep brain stimulation surgery done?

It is important to note that surgical techniques for DBS can vary among centers and surgeons. The surgical methods described here are those used by Cleveland Clinic neurologists and neurosurgeons.

DBS involves the implantation of a very thin lead containing four electrode contacts into a specific target area in the brain. The lead extends through a small opening in the skull and is connected to an extension wire. The extension wire is connected to an impulse generator or “pacemaker,” which is implanted under the skin over the chest. Programming of the DBS is easy and painless.

The surgeon is aided by computerized brain-mapping technology to find the precise location in the brain where nerve signals generate the tremors and other symptoms.

Highly sophisticated imaging and recording equipment are used to map both the physical structure and the functioning of the brain.

The patient is awake during the DBS surgery to allow the surgical team to assess the patient’s brain functions. While the electrode is being advanced through the brain, the patient does not feel any pain because of the unique nature of the human brain and its inability to generate pain signals. When the surgeon makes the small opening in the skull a local anesthetic is administered. The anesthetic used is similar to those used during a dental procedure to numb an area of the mouth.

Most DBS patients are in the hospital for about three days. The stimulators are implanted below the collarbone either at the time of electrode implantation or later. The DBS patient is placed under general anesthesia for this part of the procedure. The stimulators are turned on for the first time within a few weeks after implantation.

How effective is Deep Brain Stimulation?

In properly selected patients, DBS is remarkably safe and effective, although not completely without risk. Beneficial effects have been demonstrated to last for several years. Patients who initially responded well to medications, but over time have developed side effects, can experience between 60 to 80 percent improvement in such symptoms as tremor and slowness of movement. Patients on average report a 50 percent improvement in their walking and balance after DBS. Similarly, patients with involuntary movements (dyskinesia) due to their medications, experience over 80 percent reduction in their involuntary movements. Most patients are able to significantly reduce their medications following DBS.

Regarding Parkinson’s disease in particular, an important indicator of the effectiveness of any treatment is the duration of “on-time” without dyskinesia. This means the patient is mobile, can perform everyday tasks without experiencing the involuntary movements. On average, DBS doubles the amount of “on-time” without dyskinesia.

What risks are associated with deep brain stimulation?

As with any surgery, the procedure is not entirely risk free. There is approximately a two to three percent chance of brain hemorrhage that may be of no significance, or may cause paralysis, stroke, speech impairment or other major problems. This means that for every 100 patients who undergo surgery, two or three will experience a permanent or severe complication. However, this also means that many patients will have no complications. There is a 15 percent chance of a minor or temporary problem. Rarely, infections can occur. While treatment of infection may require removal of the electrode, the infections themselves have not caused lasting damage.

The electrode that is implanted in the brain, and the electrical systems that provide stimulation, are generally very well tolerated with no significant changes in brain tissue around the electrodes.

What happens after DBS surgery?

A series of adjustments in the electrical pulse will be made over the next weeks or months. It is necessary for patients to be able to travel to a location where the stimulation of their implanted pacemakers can be adjusted following surgery. The first few follow-up visits should be to the center where the surgery was performed, but subsequent electrical programming can take place at another medical center.

Who can be evaluated for deep brain stimulation?

Patients with Parkinson’s disease, essential tremor, dystonia or tremor due to multiple sclerosis, with movement related symptoms that cannot be controlled by medications can be evaluated as possible candidates for DBS. In addition, patients who experience intolerable side effects from medication may also be candidates.

DBS has been successful in treating patients as young as 13 years of age. In general, surgery is performed on those under 75 years of age. However, each patient must be assessed individually concerning his or her stamina and overall health.

Has deep brain stimulation been approved by the Food and Drug Administration?

Yes. In January of 2002 the FDA approved DBS for the treatment of Parkinson’s disease. It had previously been approved for the treatment of essential tremor.

Does Medicare cover deep brain stimulation?

This Food and Drug Administration (FDA) approved procedure is covered by Medicare for the treatment of Parkinson’s disease, essential tremor. However, this is not the case in all states. Some states’ programs do not cover DBS surgery. Outside of Medicare, most insurance companies are also covering the costs of DBS surgery. To determine if Medicare in your state, or your individual insurance policy covers all or a portion of the costs, you would need to contact your benefit representative directly. If you need assistance with this, please do not hesitate to contact us.

How does Cleveland Clinic perform deep brain stimulation surgery?

DBS involves the implantation of a very thin lead containing four electrode contacts into a specific target area in the brain. The lead extends through a small opening in the skull and is connected to an extension wire. The extension wire is connected to an impulse generator or “pacemaker,” which is implanted under the skin over the chest.

Programming of the DBS is easy and painless. The surgeon is aided by computerized brain-mapping technology to find the precise location in the brain where nerve signals generate the symptoms. Highly sophisticated imaging and recording equipment are used to map both the physical structure and the functioning of the brain.

The DBS patient is awake during surgery to allow the surgical team to assess the patient’s brain functions. While the electrode is being advanced through the brain, the patient does not feel any pain because of the unique nature of the human brain and its inability to generate pain signals. When the surgeon makes the small opening in the skull a local anesthetic is administered. The anesthetic used is similar to those used during a dental procedure to numb an area of the mouth. Most DBS patients are in the hospital for about three days. The stimulators are implanted below the collarbone either at the time of electrode implantation or later. The patient is placed under general anesthesia for this part of the procedure. The stimulators are turned on for the first time within a few weeks after implantation.

The U.S. Food and Drug Administration has approved the use of DBS for Parkinson’s disease and essential tremor as well as in patients with OCD under a humanitarian device exception. Trials are being done to determine its effectiveness in treating depression. Potential patients will need a physician’s referral to be considered for these studies.

Research into DBS for depression

Patients may be appropriate candidates for investigational studies into DBS for depression if they meet the following criteria (procedure is invasive and only experimental at this point):

  1. Have a diagnosis of major depression (bipolar patients are not currently being enrolled)
  2. Have had the illness for at least five years and are significantly disabled by it current episode of depression has lasted for at least two years
  3. Has failed at least four trials of antidepressants (at least two different classes) as well as augmentation with at least two agents known to be effective in this group (lithium, thyroid, antipsychotics, stimulants)
  4. No psychotic symptoms outside of an episode of depression (patient cannot currently be psychotic)
  5. No severe personality disorder present which would interfere with safety or compliance
  6. Past treatment with ECT to which the patient has either been refractory or intolerant
  7. Ability to comply with study demands (monthly visits, prolonged testing visits, etc.)

Research into DBS for obsessive-compulsive disorder

Patients may be appropriate candidates for investigational studies into DBS for OCD if they meet the following criteria (procedure is invasive and only experimental at this point):

  1. Must be severely disabled by their OCD
  2. Must be between the ages of 18 and 60
  3. Must be refractory to all reasonable treatment options, which must have included the following:
    • Three or more trials of different SSRIs, of which one must be Anafranil augmentation of SSRIs with an atypical antipsychotic, Klonopin and Buspar
    • At least 20 hours or more of exposure therapy
    • Axis I – must not include bipolar or psychotic diagnosis

For more information on DBS for depression and OCD, call the Cleveland Clinic Psychiatric Neuromodulation Center at 216.445.3550.

For information on DBS for neurological disorders such as Parkinson’s disease, call the Center for Neurological Restoration at 216.636.5860 or toll-free 866.588.2264.

IMRIS Neuro

Innovations in DBS

For those patients that could not tolerate traditional DBS surgery, Cleveland Clinic has developed, installed and established training for an interventional MRI suite attached to a conventional operating room, called IMRIS Neuro. The MRI machine is suspended from the ceiling and moved into the operating room only when needed. The IMRIS system allows for real-time imaging scans while the patient is still in the operating room.

Guided by feedback from the system, the neurosurgeon can plan and precisely place the leads while the patient is under general anesthesia. Previously, almost all DBS required awake surgery.

This state-of-the-art facility is currently being utilized for intraoperative guidance of a variety of neurosurgical procedures, including placement of deep brain stimulators and laser ablation therapy for intracranial neoplasms.

The combination of DBS with our intraoperative MRI capability streamlines the procedure within a single room. At Cleveland Clinic, the integration of technologies represents a significant advance in patient safety, reduced procedure time and better outcomes.

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