Deep Brain Stimulation in Parkinson's disease

1 - Which patients can benefit from a Deep Brain Stimulation in Parkinson's disease?

Patients affected by Parkinson's disease for at least 4-5 years and well responsive to treatment with levo dopa and dopamine agonists. Remember that the diagnosis of Parkinson's disease is mostly clinical and is also based on its temporal evolution. Generally, the surgical treatment is reserved to patients that manifest the complications of dopaminergic therapy, as the dyskinesia, dystonia and motor blocks. Patients with Parkinson's disease eligible for brain stimulation surgery, should undergo Nuclear Brain Resonance to exclude other possible brain disorders.

 

2 - Up to what age is it possible to perform the surgery?

- 70 years is usually considered the limit to undergo surgery treatment. This threshold has to be carefully assessed regarding patient's clinical characteristics. Today, the biological age is more considered than the chronological age. Clinical, cognitive data and brain parenchyma characteristics are carefully evaluated in order to give indication for surgical treatment. The surgery positively influences motor symptoms with benefit on the quality of life but does not stop the progression of the disease, for this reason it should be considered as an integral part of multidisciplinary therapeutic management in younger patients.

 

3- How is the surgical treatment performed?

- The deep brain stimulation technique consists in the placement of electrodes about 1 millimeter of diameter in the nuclei of gray matter inside the brain, precisely in the nuclei of the base. Stereotaxic technique is used to obtain the precise positioning of the electrodes. This requires the location of fixed markers on the skull, that can be obtain with a stereotaxic helmet or, recently, without the latter (frameless technique) but instead using a small screws inserted on the skull. The surgery consists in two phases: the first one is generally performed under awake surgery, monitoring the registration of the cells of the nuclei of the base and then, with their stimulation, identify the benefic and side effects and the stimulation threshold; follows the second phase, in general anesthesia, during which the electrodes placed in the nuclei will be connected to a pacemaker placed in supraclavicular region.

 

4 - Which targets are generally used?

- The target of deep brain stimulation are structures of gray matter (neuronal) that are located in the deep brain, called nuclei of the base. Deep brain stimulation in patients with Parkinson's disease is generally performed bilaterally. The subthalamic nucleo (STN) and the inner part of the pale globe (GPI) are usually the most used target. Their high-frequency stimulation remodulate the pathological electrical alteration of the network that controls movement. The chronic stimulation of the subthalamic nucleus allows, in the post-operative period, to obtain an important reduction of dopamine agonist therapy.

 

5- Does the pacemaker have to be replaced and how many years does it last?

- The life of the neurostimulator or pacemaker is variable, usually is around 3-6 years and strongly depends from the stimulation parameters. Today, there are also rechargeable neurostimulators having longer duration but that require careful compliance by the patient and the caregiver and therefore should be implanted according to very scrupulous clinical criteria and on the indication of the clinicians.

 

 

Dott. Riccardo Antonio Ricciuti
Direttore U.O.C. Di Neurochirurgia – ASL di Viterbo

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