surgery for parkinson’s disease: focus on deep brain stimulation ramón l rodríguez, md director...

Surgery for Parkinson’s Disease:Focus on Deep Brain Stimulation

Ramón L Rodríguez, MDDirector of Clinical Services

University of Florida

Movement Disorders Center

ramon.rodriguez@neurology.ufl.edu

Parkinson’s Disease Progressive neurodegenerative disease Affects the substantia nigra, which

produces dopamine As a result, the patient develops the four

cardinal symptoms of PD: Resting tremor, slowness, stiffness and balance

problems

Parkinson’s Disease Shows a good response to levodopa

(Sinemet) Medications help improves the cardinal

symptoms of the disease Patients derive great benefit from the

medication for a period of 5-7 years

Parkinson’s Disease With time, patients may develop motor

fluctuations or side effects induced by levodopa

This motor fluctuations may become the most disabling aspect of the disease

Parkinson’s Disease Wearing off Unpredictable off Sudden off Dose failures On-Off fluctuations

Parkinson’s Disease Levodopa induced Dyskinesias

Diphasic Dyskinesias Peak dose Dyskinesias Levodopa induced Dystonia

Parkinson’s disease Development of this symptoms may take

the disease from a non disabling to a disabling state

At this stage, medical management may be difficult and accompanied by undesirable side effects

Parkinson’s Disease What can be done at this stage?

Surgery for Parkinson’s Disease Pallidotomy Thalamotomy Subthalamotomy Deep Brain Stimualtion [DBS]

Terapia Activa

What is DBS? Deep Brain Stimulation

Device similar to a pacemaker Provides an electrical discharge to specific brain

area This stimulation modulates the brain signals that

causes the symptoms of Parkinson’s disease

Deep Brain Stimulation Not a cure for PD Does not replaces medications for PD Does not alter the mechanism of action of

medications

Deep Brain Stimulation Improves the cardinal symptoms of

Parkinson’s disease Smooth out motor fluctuations Increase “on” time Prevents disabling “off” periods

Deep Brain Stimulation Reversible procedure Side effect profile much more benign than

lesioning procedures Can be done bilaterally As the disease advances, it can be

modified

Deep Brain Stimulation

Deep Brain Stimulation

Deep Brain Stimulation

Deep Brain Stimulation

Deep Brain Stimulation

Microelectrode Recording

STN

Border/SN

10sec

10sec

10sec

80ms

80ms

80ms

Sagittal Section Through the Thalamus Border

Intraoperative somatosensory evoked responses

Microelectrode Mapping

Deep Brain Stimulation

Deep Brain Stimulation Requires patient commitment for

programming 64,000 different combinations Patience from both patient and

programmer

Deep Brain Stimulation Battery needs to be replaces every 3-6

years Potential Complications

Infection Lead fracture Lead Migration Skin erosion Mood and Behavioral changes

Deep Brain Stimulation DBS is not for every patient Proper patient selection is critical for

success Proper placement of the device is required

for success

Who is the best candidate? Disabling motor fluctuations Significant proportion of day spent in

disabling “off” state Symptoms improve with levodopa Patients suffering from disabling

dyskinesias

Not ideal candidate Poor response to levodopa Cognitive deficits or dementia Hallucinations not related to medications Patients diagnosed with Parkinson’s plus

syndromes (MSA, Lewy Body Disease, Corticobasal Degeneration, Progressive Supranuclear Palsy)

Thank You!!!