Surgery - New Tool Associated with DBS #


New Tool to Detect Real Time Chemical Changes in the Brain

Copied from The Northwest Parkinson’s Foundation Weekly News Update

Amber Moore

Medical Daily - Researchers have created a new tool that can track chemical changes in the brain as they happen in people undergoing Deep Brain Stimulation (DBS). This technology can help analyze and adjust these chemicals in the brain to treat disorders like Parkinson's disease, depression or other disorders that occur due to chemical imbalances in the brain.

Researchers say that by understanding how the brain works, physicians can make informed choices about a treatment.

"We can learn what neurochemicals can be released by DBS, neurochemical stimulation, or other stimulation. We can basically learn how the brain works," said author Su-Youne Chang, PhD, of the Neurosurgery Department at the Mayo Clinic.

Researchers can see changes in the brain as they happen without relying on external feedbacks like tremors. They were able to observe real time changes in a neurotransmitter called adenosine.

"We can't watch pain as we do tremors. What is exciting about this electrochemical feedback is that we can monitor the brain without external feedback. So now, we can monitor neurochemicals in the brain and learn about brain processes like pain," said Kendall Lee, MD, PhD, a Mayo Clinic neurosurgeon.

DBS has been shown to be effective in treating people with brain disorders. Tremors can be reduced in people by inserting DBS electrodes before electrical stimulation. Researchers say that this finding will lead to advanced DBS systems.

"With the stimulator and detection, we can create algorithms and then raise neurotransmitters to a specified level. We can raise these chemicals to appropriate levels, rising and falling with each person throughout their life. Within milliseconds, we can measure, calculate and respond. From the patient's perspective, this would be essentially instantaneous," said Kevin Bennet, a Mayo Clinic engineer who helped create the system.

Deep brain stimulation involves implanting electrodes within the part of the brain that regulates mood. The Food and Drug Administration has not approved deep brain stimulation for treatment of depression.The study will be published in Mayo Clinic Proceedings.


Surgery - Another New Technique for DBS #


New technique for deep brain stimulation surgery proves accurate and safe

Copied from The Northwest Parkinson’s Foundation Weekly News Update

OHSU News - The surgeon who more than two decades ago pioneered deep brain stimulation surgery in the United States to treat people with Parkinson's disease and other movement disorders has now developed a new way to perform the surgery — which allows for more accurate placement of the brain electrodes and likely is safer for patients.

The success and safety of the new surgical technique could have broad implications for deep brain stimulation, or DBS, surgery into the future, as it may increasingly be used to help with a wide range of medical issues beyond Parkinson’s disease and familial tremors.

The new surgery also offers another distinct advantage: patients are asleep during the surgery, rather than being awake under local anaesthesia to help surgeons determine placement of the electrodes as happens with the traditional DBS surgery.

A study detailing the new surgical technique is being published in the June 2013 edition of the Journal of Neurosurgery, and has been published online at the journal's website.

"I think this will be how DBS surgery will be done in most cases going forward," said Kim Burchiel, M.D., F.A.C.S., chair of neurological surgery at Oregon Health & Science University and the lead author of the Journal of Neurosurgery article. "This surgery allows for extremely accurate placement of the electrodes and it's safer. Plus patients don't need to be awake during this surgery -- which will mean many more patients who can be helped by this surgery will now be willing to consider it."

DBS surgery was first developed in France in 1987. Burchiel was the first surgeon in North America to perform the surgery, as part of a Food and Drug Administration-approved clinical trial in 1991.

The FDA approved the surgery for "essential tremor" in 1997 and for tremors associated with Parkinson's disease in 2002. The surgery has been performed tens of thousands of times over the last decade or so in the United States, most often for familial tremor and Parkinson's disease. Burchiel and his team at OHSU have performed the surgery more than 750 times.

The surgery involves implanting very thin wire electrodes in the brain, connected to something like a pacemaker implanted in the chest. The system then stimulates the brain to often significantly reduce the tremors.

For most of the last two decades, the DBS patient was required to be awake during surgery, to allow surgeons to determine through monitoring the patient’s symptoms and getting other conscious patient feedback whether the electrodes were placed in the right spots in the brain.

But the traditional form of the surgery had drawbacks. Many patients who might have benefitted weren't willing to undergo the sometimes 4 to 6 hour surgery while awake. There also is a small chance of haemorrhaging in the brain as the surgeon places or moves the electrodes to the right spot in the brain.

The new technique uses advances in brain imaging in recent years to place the electrodes more safely, and more accurately, than in traditional DBS surgery. The surgical team uses CT scanning during the surgery itself, along with an MRI of the patient's brain before the surgery, to precisely place the electrodes in the brain, while better ensuring no haemorrhaging or complications from the insertion of the electrode.

The Journal of Neurosurgery article reported on 60 patients who had the surgery at OHSU over an 18-month period beginning in early 2011.

"What our results say is that it's safe, that we had no haemorrhaging or complications at all — and the accuracy of the electrode placement is the best ever reported," Burchiel said.

Burchiel and his team have done another 140 or so surgeries with the new procedure since enrolment in the study ended. OHSU was the first center to pioneer the new DBS procedure, but other surgical teams across the U.S. are learning the technique at OHSU, and bringing it back to their own centers.

The positive results with the new DBS technique could have ramifications as medical researchers nationwide continue to explore possible new uses for DBS surgery. DBS surgery has shown promising results in clinical trials with some Alzheimer's patients, with some forms of depression and even with obesity.

If the early promising results for these conditions are confirmed, the number of people who might be candidates for DBS surgery could expand greatly, Burchiel said.

The length of the new surgery for the 60 patients involved in the study was slightly longer than traditional DBS surgery. But as Burchiel and his team have developed the new surgical technique, the new DBS surgeries are usually much shorter, often taking half the time of the more traditional approach. Given that, and that the electrodes are placed more accurately and the surgery is cheaper to perform, the new DBS surgery likely will be the technique most surgeons will use in coming years, Burchiel said.

DBS surgery often helps significantly reduce tremors in patients with familial tremor and tremors and other symptoms in Parkinson’s disease. A parallel study is ongoing at OHSU to assess how symptoms of the patients have improved since their DBS surgery using this new method.


Surgery - New Method for DBS #


New method for deep brain stimulation offers promise for better treatment of Parkinson’s, say Hebrew University researchers

Copied from The Northwest Parkinson’s Foundation Weekly News Update

An article appearing in the neuroscience journal Neuron describes the method, carried out at the Hebrew University Faculty of Medicine at the laboratory of Hagai Bergman, Simone and Bernard Guttmann Professor of Brain Research at the Edmond and Lily

Health Canal - Deeply stimulating: Prof. Hagai Bergman (right) and MD-PhD student Boris Rosin A new method for dynamic, electronic deep brain stimulation (DBS) developed at the Hebrew University of Jerusalem offers promise for better treatment of the symptoms of Parkinson’s disease.

The research was carried out by MD-PhD student Boris Rosin, Prof. Bergman and other members of the research team.

The suggested treatment involves an improvement of the existing deep brain stimulation (DBS) method. In DBS an electrode is implanted in a deep region of the brain, serving as a “brain pacemaker” delivering electrical stimuli at the implantation site. The result is that the patient receives a measure of immediate relief from these symptoms.

The new system uses real-time adaptive stimulation which disrupts the pathological neuronal activity associated with Parkinson’s disease instead of delivering constant stimulus. The research shows that this adaptive disruption, which the authors term closed-loop deep brain stimulation, is much more efficient than the constant electrical current stimulation being used in DBS today.

Although the underlying principles of its actions are not entirely clear, DBS has provided significant therapeutic benefits for movement disorders like Parkinson’s and for disorders like chronic pain and major depression. Under current practice, stimulation parameters, such as frequency and intensity of stimulation, must be programmed and adjusted over several months by a highly trained clinician following implantation of the DBS device, the goal being to maximize clinical improvement and minimize stimulation-induced side effects.

These adjustments typically occur every three to 12 months when the patient visits the clinic, with the parameters remaining the same between visits. Unfortunately, this results in stimulation that does not keep up with the dynamic nature of Parkinson’s.

“In recent years, the role of Parkinson’s-driven aberrant discharge patterns of neuronal activity have emerged as pivotal in the pathophysiology of the disease, and there is an urgent need for an automatic and dynamic system that can continually adjust the stimulus in response to ongoing pathological changes,” explain Rosin and Bergman.

To meet this challenge, the researchers tested several new paradigms for real-time adaptive DBS in a primate model of Parkinson’s disease, in which the delivered stimulus was triggered by the ongoing brain activity.

The researchers discovered that real-time adaptive DBS paradigms alleviated Parkinson’s motor symptoms and reduced abnormal neural activity more efficiently than standard, periodically adjusted DBS, while also providing new insight into brain activity underlying Parkinson’s pathology.

“It is our hope that in the near future we will see a new era of DBS strategies, based on real-time adaptive paradigms targeted at different pathological brain activity,” conclude Rosin and Bergman.

“This new stimulation strategy has the potential of being instrumental in the treatment of additional brain disorders in which a pathological brain activity pattern can be recognized and targeted by closed-loop stimulation”, the researchers say.

“These disorders also include prevalent psychiatric disorders such as obsessive-compulsive disorder, depression and even schizophrenia, which display pathological patterns of brain activity that bear certain similarities to those seen in Parkinson's disease.”




Surgery - Safe Alternative to DBS #


Less Invasive Method of Brain Stimulation Helps Patients with Parkinson's Disease

Copied from The Northwest Parkinson’s Foundation Weekly News Update

Electrical stimulation using extradural electrodes—placed underneath the skull but not implanted in the brain—is a safe approach with meaningful benefits for patients with Parkinson’s disease, reports the October issue of Neurosurgery, official journ

Science Blog - The technique, called extradural motor cortex stimulation (EMCS), may provide a less-invasive alternative to electrical deep brain stimulation (DBS) for some patients with the movement disorder Parkinson’s disease. The study was led by Dr. Beatrice Cioni of Catholic University, Rome.

Study Shows Safety and Effectiveness of Extradural Brain Stimulation

The researchers evaluated EMCS in nine patients with Parkinson’s disease. Over the past decade, DBS using electrodes implanted in specific areas within the brain has become an accepted treatment for Parkinson’s disease. In the EMCS technique, a relatively simple surgical procedure is performed to place a strip of four electrodes in an “extradural” location—on top of the tough membrane (dura) lining the brain.

The electrodes were placed over a brain area called the motor cortex, which governs voluntary muscle movements. The study was designed to demonstrate the safety of the EMCS approach, and to provide preliminary information on its effectiveness in relieving the various types of movement abnormalities in Parkinson’s disease.

The electrode placement procedure and subsequent electrical stimulation were safe, with no surgical complications or other adverse events. In particular, the patients had no changes in intellectual function or behavior and no seizures or other signs of epilepsy.

Extradural stimulation led to small but significant and lasting improvements in control of voluntary movement. After one year, motor symptoms improved by an average of 13 percent on a standard Parkinson’s disease rating scale, while the patient was off medications.

‘Remarkable’ Improvement in Walking and Related Symptoms
The improvement appeared after three to four weeks of electrical stimulation and persisted for a few weeks after stimulation was stopped. In one case where the stimulator was accidentally switched off, it took four weeks before the patient even noticed.

Extradural stimulation was particularly effective in relieving the “axial” symptoms of Parkinson’s disease, such as difficulties walking. Patients had significant improvement in walking ability, including fewer problems with “freezing” of gait. The EMCS procedure also reduced tremors and other abnormal movements while improving scores on a quality-of-life questionnaire.

Although DBS is an effective treatment for Parkinson’s disease, it’s not appropriate for all patients. Some patients have health conditions or old age that would make surgery for electrode placement too risky. Other patients—including four of the nine patients in the new study—are eligible for DBS but don’t want to undergo electrode placement surgery.

The concept of extradural stimulation is not new, but previous studies have had important limitations, with inconsistent results. The new report is the largest study of EMCS performed using a standard technique in a well-defined group of patients.

The findings show that extradural stimulation is not only safe for patients with Parkinson’s disease, but also effective in improving movement disorder symptoms—with “remarkable effects on axial symptoms,” according to Dr. Cioni and colleagues. Although the improvement is not as great as with DBS, the researchers believe that EMCS “should be considered as an alternative option” for at least some groups of patients. Further studies, including long-term follow-up, are underway.


Surgery - DBS Deep Brain Stimulation #


Jim Kennedy puts Parkinson's on pause

Copied from The Northwest Parkinson’s Foundation Weekly News Update

Ashley Gebb/ADagebb - It started with stuttering.

Then came pain and the loss of fine motor skills. Eventually, Jim Kennedy found it impossible to put in his contacts, punch numbers on his cellphone or even turn around.

Life with Parkinson's disease had made the sharp, active man a prisoner in his own body.

"I went in and said, 'I can't do this anymore,'" Yuba County's former treasurer-tax collector said of a trip to the doctor that eventually led to a new lease on life.

Now 66, Kennedy was diagnosed with Parkinson's five years ago. A degenerative neurological disorder resulting from the loss of dopamine-producing brain cells, it affects about half a million people in the United States, with an additional 50,000 cases diagnosed every year.

Kennedy has an atypical version of the disorder, lacking the signature trembling by which it is most often recognizable but suffers from other frustrating and painful symptoms.

Despite suspicions, he lived in denial for a long time before his diagnosis.

"I said, 'I can't have that, I don't have that,'" he said.

But his wife, Wendy, a registered nurse, saw the symptoms clearly.

Kennedy, a member of the Yuba Community College District board and other community boards, had begun to stutter for the first time in his life and was walking with shoulders hunched while shuffling his feet.

When Wendy pressed him to explain the pain, offering all the diagnostic analogies she could think of, he said he felt like he had jammed his fingers in a light socket and electric current jolted down his center.

The only way to officially diagnose Parkinson's is by administering medication and seeing if it works. So, the Kennedys finally went to the doctor.

"A half hour later, I felt better and it was like, 'S---, that's what it is,'" Kennedy said.

After his diagnosis, he read as little about the disorder as he could.

"I didn't want to know. I knew it was going to be crummy," he said. "And if I didn't know, it wouldn't affect me — wrong."

Prisoner of Parkinson's

As the disease progressed, Kennedy could no longer roll over in bed or to walk the porch around his Browns Valley home without falling down. He lost about 50 pounds and Wendy began attending Yuba College board meetings with him to help him stand and sit.

"It's heartbreaking, but the hardest part was watching him deal with the loss of who he perceived himself to be," Wendy said.

John Cassidy, chief executive officer of Sierra Central Credit Union, where Kennedy is a board member, called every day — and still does — to check in. And when Wendy had to go to Seattle to take care of her mother, another friend came and stayed with Kennedy in the foothills for two weeks to help with the most basic of needs.

"I've found out who my friends are, and it's really nice to know how many I have," Kennedy said.

Despite medication, his symptoms worsened, and six months ago, he could not mask his condition any longer. He announced he had Parkinson's during a Yuba College board meeting.

It was around that time he went to his neurologist, Dr. Wenchiang Han at Rideout Health, to see what could be done. Han referred Kennedy to Stanford University School of Medicine, where he met with a neurosurgeon about the possibility of deep brain stimulation.

The two-day surgery involves implanting a neurostimulator, kind of like a pacemaker, into the chest, and inserting four thin wires about 4 inches into the brain with electrodes targeting the affected area. An extension wire connecting the lead to the neurostimulator transmits electrical impulses that block signals causing the Parkinson's symptoms.

To qualify, he underwent a barrage of cognitive and skill tests and evaluations to see that he was strong enough mentally and physically to undergo surgery.

Kennedy's neurosurgeon at Stanford only does two of the surgeries a month but was able to schedule him for the procedure Sept. 6.

"The surgery itself was one of the scariest things I have ever done in my life," Kennedy said, noting he was awoken mid-procedure and asked to move his limbs so surgeons would know they were in the correct parts of his brain.


Dr. Han, who started seeing Kennedy in 2007, said in being relatively young and in good health, Kennedy was an ideal candidate for the procedure, especially as the disorder continued its natural progression of decline.

"Usually, it starts with the shaking. At that stage, it's an annoyance, but it doesn't interfere," he said. "But as the disease progresses, you get trapped in your own body. Your mind is perfectly clear, and you can't do anything. I think that's very horrible for people to go through."

Han is hopeful that with medicine, surgery and advances in technology, quality of life can continue to improve for Parkinson's patients.

"We are doing quite well with what we are doing compared to years ago," he said. "Luckily, I think with what we have nowadays, we can manage it OK."

Wendy, who had retired early to help care for her husband, said that once approved, the decision to proceed with surgery was easy.

"It was, do it now or I don't know where he was going to be six months from now," she said.

After surgery, a change could be seen almost immediately.

His body, which had been tensed for years as a result of the symptoms, finally relaxed. His stuttering reduced, and he was able to take long strides again. Kennedy doesn't know if he ever will be able to return to golf — one of his favorite activities — but that's OK.

"It's like a miracle," he said. "The state of modern medicine is absolutely mind-boggling. What they were able to accomplish with me, I can't believe it ... If this is as good as it gets, it's so much better than it was, I'm fine."

Kennedy returns to Stanford in two weeks to begin to calibrate the neurostimulator. It will take up to a year to fully program the device, but he can expect to see benefits of the surgery for about 10 years.

"It's not a panacea. It's not going to cure anything. It's gonna help with some of the more severe symptoms," he said.

The one thing it won't help with is the few people Kennedy can relate to about the disease and find some validation for his feelings and frustrations, because even though the disorder is not uncommon, it is not relatively widespread.

If anyone in the community is suffering from Parkinson's and wants to talk to him, he says he is listed in the phone book.

"It's a lonely existence," he sad. "Anyone I can help, I'd be happy to talk to them. I'm not an expert, I'm just a poor bastard whose got it."