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Deep Brain Stimulation - Frequently Asked Questions
Deep Brain Stimulation (DBS)
DBS for Parkinson's Disease
DBS for Essential Tremors
DBS for Dystonia
Deep Brain Stimulation (DBS) at Stanford
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What is deep brain stimulation (DBS)?
Sometimes called a “brain pacemaker,” deep brain stimulation uses a surgically implanted device, similar to a cardiac pacemaker, to deliver electrical stimulation to precisely targeted areas in the brain. Continuous stimulation to these brain regions in the brain blocks the signals that cause the disabling motor symptoms of Parkinson’s Disease and Essential Tremor.
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How long has deep brain stimulation been used?
Neurosurgeons began implanting deep brain stimulators for movement disorders in the 1980’s.
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How does Deep Brain Stimulation help Parkinson’s disease patients?
DBS can help decrease the tremor rigidity and slowness of movement that affect most Parkinson’s Disease patients. Unlike medication, the stimulator remains “on” at all times, providing most patients with relief from the fluctuations they experience with medication. Most patients can reduce their Parkinson’s medications significantly – often in half. People who experience dyskinesias (abnormal involuntary movements) caused by their Parkinson’s medications, often find that decreasing medications after DBS surgery can dramatically reduce this symptom. DBS does not cure Parkinson’s disease, but it can effectively treat many of the symptoms and helps improve motor function.
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Who is a candidate for surgery?
The best candidates for DBS for Parkinson’s disease are patients who have had a a good response to Sinemet but are now developing side effects and fluctuations in functioning related to the medication. Serious medical problems or difficulty with cognitive function (thinking and remembering) may make a patient less likely to do well with surgery. Although there is no upper age limit, the benefits of DBS for Parkinson’s disease seem to decline with advancing age.
Patients with dementia, no benefit from levodopa (Sinemet) or with a disease that mimics Parkinson’s – often called atypical parkinsonism or Parkinson’s plus syndrome – do not usually benefit significantly from DBS surgery.
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How does Deep Brain Stimulation help Essential Tremor patients?
DBS can dramatically reduce tremor in the arms and/or legs in patients with Essential Tremor. Head tremor or voice tremor can sometimes be improved as well, although usually not as dramatically as tremor in the limbs. DBS is considered as a treatment alternative for Essential Tremor patients whose symptoms cannot be managed successfully with medication therapy or who have intolerable side effects from medication therapy. Deep Brain Stimulation does not cure Essential Tremor, but it controls the symptoms (shaking). Some patients will elect to have the deep brain stimulator implanted on one side of the brain only – this controls the opposite side of the body. (example: a right handed person would have their left side of the brain implanted to control their right hand tremor). Other patients will elect to have bilateral deep brain stimulators.
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How does the stimulator help dystonia patients?
Deep Brain Stimulation for dystonia is generating interest because it is reversible and adjustable, unlike the older type of dystonia surgery that created a permanent surgical lesion (pallidotomy). It is used for the treatment of chronic, drug refractory, primary dystonia – including generalized, segmental, hemidystonia and cervical dystonia. Adults and children within these parameters may be candidates. Certain types of young people with a genetic form of dystonia, the DYT-1 mutation, often have an excellent response to surgery. Deep Brain Stimulation for certain types of dystonia has been designated a Humanitarian Use Device (HUD) by the FDA. A Humanitarian Use Device is a device that is intended to benefit patients in the treatment or diagnosis of diseases or conditions that affect fewer than 4,000 individuals per year in the U.S. Insurance usually pays for deep brain stimulation for dystonia, but may deny payment in some cases since DBS for dystonia is not a standard treatment. It generally takes 3 - 12 months after deep brain stimulation surgery to see improvement in dystonia symptoms. Symptom improvement may vary depending on the type of dystonia, the length of time the patient has had the symptoms and the severity of the symptoms. The Deep Brain Stimulation surgery will not cure dystonia; the goal is some improvement in symptoms.
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What are the components of the deep brain stimulator?
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DBS lead – a thin, insulated coiled wire with four electrodes at the end. The neurosurgeon places these electrodes in areas of the brain called the thalamus (VIM), the subthalamic nucleus (STN) or the internal globus pallidus (GPi) depending on the patient’s condition.
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Neurostimulator – a device containing a battery and microelectronic circuitry. It is implanted under the skin near the collarbone and generates electrical signals that are delivered to the targeted structures in the brain.
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Extension – an insulated wire that is passed under the skin to connect the lead to the implanted neurostimulator.
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What are the potential risks of surgery?
Implanting the deep brain stimulators carries the same risks associated with any other brain surgery. Risks may include:
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Brain hemorrhage (1.5 percent)
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Leakage of cerebral spinal fluid surrounding the brain
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Infection (3 - 5 percent)
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Seizure
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Stroke
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Confusion or attention problems
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Speech difficulty
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How long does the neurostimulator battery last?
On average, three to five years. When it needs to be changed, the entire implantable pulse generator is replaced. This is an outpatient procedure and can be done under local or general anesthesia.
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Are there any procedures patients must avoid if they have an implanted deep brain stimulator?
Patients must avoid:
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Is there an effect on the deep brain stimulators when a patient is near electronics?
Most electrical devices will not harm the system. If the neurostimulator comes within inches of small permanent magnets (such as stereo speakers, radios, refrigerator door magnets), it could be turned off or on. The patient will be given a hand held access review device to turn their stimulator back on if it is deactivated.
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Will health insurance cover DBS surgery?
Medicare and most private insurers cover DBS surgery. Insurance authorization is obtained before the patient is admitted to the hospital.
- What is the surgical process at Stanford?
During the initial evaluation, the patient will be seen by our neurologist, neurosurgeon and neuropsychologist. The visit with the neurologist will include evaluating the patient in an on- and an off-medication state. An MRI of the brain may be done, of the patient has not recently had one. Following these evaluations, the Movement Disorders Surgical review board meets to consider the appropriateness of surgery for each patient. The patient is notified of the board’s discussion either by telephone or by a return clinic visit. The final decision for surgery is made following a discussion between the patient and neurosurgeon.
The week of surgery, patients will be tested in the Stanford Human Motor Control and Balance lab. They will also have a consultation with anesthesia, an MRI of their brain for surgical targeting and a pre-operative history and physical. The day before surgery, the patient’s head will be shaved and the patient will have “fiducials” placed in his/her scalp. These are small titanium screws which serve as markers and assist in computerized targeting for the exact DBS lead location during surgery. The scalp is numbed with anesthetic before these are placed. After these are placed, the patient will have a CT scan. The fiducials remain in until after both DBS leads are placed.
Our surgical process is usually staged, with each side of the brain done on a separate day. In certain situations, both sides may be done on the same day. The patient is awake during the operation and is free to move his/her head, arms and legs. The patient will have his/her scalp anesthetized before the lead implant procedure. The patient usually has a catheter inserted into the bladder and an IV (intravenous catheter) in one arm. At the beginning of the operation, sedation is given to improve comfort and decrease anxiety.
Implantation of the DBS lead is performed using a state of the art frameless technique pioneered by Dr. Jaimie Henderson. In the operating room, our neurologist, Dr. Bronte Stewart and our neurosurgeon, Dr. Henderson, will perform micro-electrode mapping of the target nucleus to determine the exact target for the DBS lead. This helps maximize the precision of the surgery and improve the surgical outcome. The lead is inserted through a small opening in the skull called a burr hole.
The patient will be asked questions and may be asked to perform some tasks during surgery – such as counting or moving their toes or fingers. This helps the physicians to test the stimulation and maximize the symptom control, while minimizing side effects. The patient will spend one night in the hospital after each DBS lead is placed. Each side of the DBS placement generally takes three to four hours.
The neurostimulator/s is placed with the patient is under general anesthesia. This is an outpatient procedure and usually takes one to two hours. A small incision is made near the collarbone, and the neurostimulator is implanted under the skin. It is connected to the deep brain stimulator lead by an extension, which is passed under the skin of the scalp, neck and shoulder. It can be done on a separate day from the brain surgery or, in some cases, on the same day.
The patient may be given the option of having one slightly larger neurostimulator (Kinetra) or two smaller neurostimulators (Soletra) placed.
Programming of the deep brain stimulators usually takes place 3 to 4 weeks after the deep brain stimulation surgery is completed. |
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