Chronic deep brain stimulation is a rapidly emerging therapy for advanced Parkinson disease. Deep brain stimulation surgery technique involves implanting electrodes inside the deep nuclei of brain called as subthalamus under local anesthesia. These electrodes are then connected to IPG (Pacemaker) implanted underneath the skin below the clavicle through the connecting leads under general anesthesia. To perform any kind of activity, the patient has to switch on the device with the help of a patient programmer. This stimulates the deep brain nuclei, which results in improvement of all the symptoms of Parkinson disease.
With the progress of disease the parameters of stimulation are changed over a period of time so that patients can remain symptom free for long period. The patient himself can change the stimulation parameters with the help of patient programmer. Normally the life of the pacemaker is five years and after that a new pacemaker replaces it. The electrodes remain in position for life long.Rechargeble Pace makers are now available that can be recharged at home.The life of these pace makers are 10-15 years.The stimulation of subthalamic nucleus through this device leads to improvement in all the symptoms of advanced Parkinson disease.
DBS is a surgical procedure used to treat a variety of disabling neurological symptoms.
Dr. Alok Gupta
Dr. Alok Gupta is the senior consultant neurosurgeon at Metro Multispeciality hospital Faridabad, one of the leading hospitals in National capital region. Having qualifications like M.ch Neurosurgery, M.S. (Gen.Surgery) and M.B.B.S. the main aim or motive of Dr. Gupta remains to provide top- notch services in the field of Stereotactic neurosurgery. Dr. Gupta had been associated with some of the leading hospitals of India such as Artemis Health Institute Gurgaon, Max Multispecialty hospital Saket New Delhi and VIMHANS New Delhi.
Dr. Alok Gupta is performing Deep Brain Stimulation surgeries since 1998 and so far has perform more than 500 procedures for various indications. He is credited for starting First DBS for Parkinson disease in 1998 in India, First case of DBS for OCD in 2010 in Asia and first case of DBS for refractory epilepsy in 2012 in Asia.
Major achievements of Dr. Gupta have been acknowledged and applauded by various sectors of the healthcare society as well as media. Dr. Alok Gupta presented his work in various international and national congresses in various indications of Neuromodulation.
>> MRI Brain is done one day before surgery to see the deep nuclei (subthalamus) of brain.
>> Patient is kept off medication for 12 hrs.
>> This surgery is done under local anesthesia and sedation.
>> On the day of surgery Stereotactic frame (Leksell, ZD Frame) is fixed under local anesthesia, and then patient is taken to Radiology Department for CT Scanning.
>> The subthalmic target is calculated by fusing CT Scan and MRI images on work station.
>> In the operation theatre two small holes in th skull are made, Micro electrode recording is done using 5 channel MER. After analyzing the recording of MER, the track which has longest and strongest signal of sub thalamus chosen for the stimulation. If stimulation confirms the reduction of tremor,stiffness and slowness in operation theatre DBS lead is placed in that track using C-arm.
>> DBS lead is placed in that track using C-arm.
>> DBS lead is connected to IPG (Kinetra, Libra XP "Non Reahcrgeable" and Braio "Rechargeable") under general anesthesia. This procedure is done on the same day or can be done after one day under general anesthesia.
>> After the Deep Brain Stimulation electrodes implantation, the next important step of this surgery is programming. Initial programming is done in two weeks time and later-on further programming is done as out patient basis in subsequent visits.Patient can himself programme using hand held patient's programmer under guidance of a neurologist or programming assistant.
DBS(Deep Brain Stimulation) uses a surgically implanted medical device, similar to a cardiac pacemaker, to deliver electrical stimulation to precisely targeted areas within the brain. Stimulation of these areas blocks the signals that cause the disabling motor symptoms of Parkinson's disease. The electrical stimulation can be noninvasively adjusted to maximize treatment benefits. As a result, many individuals may achieve greater control over their body movements. DBS System consists of three implanted components :
>> Lead – A lead consists of four thin coiled insulated wires with four electrodes at the lead tip. The lead is implanted in the brain.
>> Extension – An extension connects to the lead and is threaded under the skin from the head, down the neck and into the upper chest.
>> Neurostimulator – The neurostimulator connects to the extension. This small, sealed device, similar to a cardiac pacemaker, contains a battery and electronics. The neurostimulator is usually implanted beneath the skin in the chest below the collarbone (depending on the patient, a surgeon may implant the neurostimulator in the abdomen).
Sometimes called a "brain pacemaker," it produces the electrical pulses needed for stimulation.These electrical pulses are delivered through the extension and lead to the targeted areas in the brain. The pulses can be adjusted wirelessly to check or change the neurostimulator settings.
Parkinson Disease is an Idiopathic, Chronic, Progressive, Degenerative disorder affecting the elderly people. However it is also seen in young people. Parkinson Disease occurs when certain nerve cells (neurons) in substantia nigra that produces dopamine chemical die or become impaired. When approx. 80% of these nerve cells(dopamine producing cells) are damaged, the symptoms of Parkinson disease appear.
Post DBS video of advanced parkinson patient "Dr. Girish"
Deep Brain Stimulation Implanted for Intractable Parkinson's Disease by Dr. Alok Gupta.
Mr. Pawan Kumar Bansal post 13 years of DBS experience.
PARKINSON DISEASE SYMPTOMS
Levadopa is a medicine which improves all the above symtoms but later on it causes abnormal movement called dyskinesia.
PARKINSON DISEASE SURGERY
Early stage of Parkinson Disease is treated by medicines.Surgery is indicated when disease has progressed and patient has developed side effects of medications.
With the help of Stereotactic Neurology Parkinson Disease e patients can be effectively treated. There are two types of stereotactic procedures available to treat these patients worldwide.
Deep brain stimulation : Mentioned above.
Pallidotomyfor Parkinson disease
Those Patients who can not affored the cost of DBS can benefit from pallidotomy. In Pallidotomy for Parkinson disease a small Thermocoagulation (circuit break) is done at postero-ventral part of Pallidum using stereotactic technique . Pallidotomy helps the patient on the controlateral side of surgery. It improves tremor, stiffness and drug induced side effects.
The Pallidotomy for parkinson disease is safe,risks and complications are rare.
Bilateral Pallidotomy is also possible but is avoided in lieu of more side effects related to surgery.
Surgery is done under local anesthesia patient is discharged after 48 hours.
Dystonia is a movement disorder that causes the muscles to contract and spasm involuntarily. The involuntary muscle contractions force the body into repetitive and often twisting movements as well as awkward, irregular postures.Dystonia may affect a single body area or be generalized throughout multiple muscle groups. Dystonia affects men, women, and children of all ages and backgrounds.
Pre video of Dystonia Patient
Dystonia causes varying degrees of disability and pain, from mild to severe. There is presently no cure, but multiple treatment options exist and scientists around the world are actively pursuing research toward new therapies.Dystonia is a chronic disorder, but the vast majority of dystonias do not impact cognition, intelligence, or shorten a person's life span. The main exception to this is dystonia that occurs as symptom of another disease or condition that can cause such complications.
Post Video of Dystonia Patient
Forms of Dystonia
Focal dystonia it involve a focal group of muscle only
Dystonia that affects the muscles of the eyelids and brow…Normally responds to Botox injection and medications.
Cervical dystonia (spasmodic torticollis)
Dystonia that affects the neck and sometimes the shoulders.. Responds to Botox injection and if not controlled Deep brain stimulation of Globus pallidus or subthalamus is good alternative.
Hand dystonia (writer's cramp)
Dystonia of the fingers, hand, and/or forearm. Respond to botox injection.
Early-onset generalized dystonia is characterized by the twisting of the limbs, specifically the foot and leg or hand and arm.
The spasms may spread to involve twisting contractions of other parts of the body.Early-onset generalized dystonia is characterized by the twisting of the limbs and torso.
They have genetic pattern and runs in family.
Respond to medications but if not controlled then Pallidal deep brain stimulation is a good alternative
A group of dystonias that respond to a medication called levodopa.
Secondary dystonia are secondary to some other disorder like trauma, Wilson disease etc. These are treated by treating the cause. They are not the good candidate for deep brain stimulation
Epilepsy is the tendency to have repeated seizures that start in the brain.Epilepsy is usually only diagnosed after a person has had more than one seizure.The incidence of Epilepsy in general population is 0.5-1%.
Asia's First Deep Brain Stimulation Implanted for Intractable Epilepsy
S.A. Faridabad Ph 09873146263
Thirty three years old female S.A. A resident of Faridabad had become the first patient in India who had Brain Pacemaker for uncontrolled Epilepsy.
At the age of 18 months she started having fits specially on her left side. It used to last for 15-20 minutes with no loss of consciousness. After fit she used to feel weakness on left side.
She was treated in local hospital in Faridabad and remained controlled with medications for 12 years. Fits started again when she failed in 12th standard. Her fits were same starting from left side and then goes to other part of body. Fits continued for 15-20 minutes and used to occur one to two times a week. Gradually the frequency of fits increased to 2-3 fits every alternate day. Many times she was admitted in I.C.U in local hospital for control of fits but again after some time they used to recur.
Till December 2011 she was confined to her house as she can have fits outside house. Her father has to remain along with her to take care of any kind of emergency.
She was referred for Epilepsy surgery. It was refused as she was not a proper candidate for surgery. She came to us in the month of January at Artemis hospital. Having exhausted all the option for medications we decided to introduce a pacemaker in very specific area of her brain called Anterior Thalamus which is a gate way through which all epileptic discharges goes to brain and then to the limbs.
She was operated on 15th January 2012
Now for last five year she is seizure free. She had one seizure when she had death in family
S.B. 26 year Male, resident of delhi
Had intractable seizures for 15 years. He had frequency of seizures 10-12 per month. Seizure type was complex partial seizures along with some generalized tonic-clonic events. His seizures were not under control despite more then three medications and was not a candidate for open surgery in view of multiple seizures activities all over brain. He was subjected to ant.thalamic deep brain stimulation on 18.05.2012.
Now his seizures are 70% under control. After three and half years he required replacement of Pacemaker as the battery got depleted. New rechargeable St Jute brio was replaced on 30th Dec. 2015 for prolonged use.
S.S. 53 years female resident of Dehradoon
Had intractable seizures for 28 years. Her seizure type was complex partial with frequent fall and frequency was 7-8 per month despite multiple medications. She was not a candidate for open surgery in view of bilateral epileptiform discharges. Deep brain stimulation surgery was done on 18.09.2012.Presently she is much better with reduction in seizure frequency to more than 70%.
Her implant battery got depleted and she required replacement in August 2014. It was replaced with rechargeable Medtronic implant for prolonged use.
R.M. 20 years female resident of Patiala
Had intrectable seiures for 9 years. The frequency of seizure was 15-20 per month. Seizures were sequalae of meningoencephalitis in childhood.She was again not a candidate for open surgery in view of generalized discharges from all over brain and MRI changes in brain. Ant. Thalamic deep brain stimulation was done on 19th April 2013. She had a stormy post-operative course with initial increase in seizures but with programming of device, seizures were controlled. Now she is seizure free and not thrown any seizure for last 3 years.
Again her pacemaker battery got depleted and was replaced with Medtronic rechargeable pacemaker.
Tremor is a normal phenomenon which is experienced by everyone. Normal tremor is referred to as "physiological tremor" and it is the slight tremor that any person will see when they, for instance, put out their hands. This tremor can be exaggerated in certain situations such as those associated with anxiety and fatigue. This is usually referred to as "exaggerated or enhanced physiological tremor".
Video of DBS in Essential tremor
Tremor can be a common symptom of neurological denhamced physiological tremoisease and may be due to trauma, tumor, stroke or degenerative disease. The most common tremor condition is idiopathic or essential (cause unknown) or hereditary tremor.
Essential Tremor is one of the most common of all neurological conditions. It is estimated that four to five million people in the United States alone have essential tremor. In most cases the disease runs in families. The condition is transmitted as an autosomal dominant inheritance, which means that the offspring of an affected individual will have a fifty percent chance of also having the illness.
Essential Tremor is a neurological disorder in which patients exhibit a rhythmic trembling of the hands, head, legs, trunk and/or voice, which is more visible during movement or with arms outstretched, than at rest. It is recognisable when seen in postural (voluntarily maintaining a position against gravity) and kinetic (performing any kind of movement) positions. Thus, essential tremor is considered an "action" tremor. It is not believed to be associated with any disease or condition.
It can affect persons of any age, gender (both genders are equally affected) and race, it can start in adolescence or adulthood and in the majority of cases, it is inherited. The mean age at onset is 45 years. While more commonly seen in older individuals, ET can begin as early as birth. The age of onset, body part(s) affected and the severity of the tremors, typically differ from patient to patient, even within the same family. This difference from patient to patient holds true for benefits received from drug therapy as well. When tremor begins ins the very elderly it has sometimes been called senile tremor The condition is slowly progressive and tremor will worsen overtime. Some individuals may have to change occupations (i.e. dentists and draftsman) or have to take early retirement.
Tremor may involve different body parts. Most often the hands are affected. Usually the dominant hand is first affected and eventually both hands may be involved. Handwriting becomes less legible and drinking liquids is difficult to manage. The individual may have to use both bands or use a straw to drink. Eating soup may become impossible. It may no longer be possible to sign a cheque in a bank or serve coffee at a luncheon. Dysfunction with fine manipulation and embarrassment are also problems. Tremor of the head may also occur. The shakiness may be a 'yes-yes" or a "no-no" movement. Embarrassment and social withdrawal may result from head tremor. Shakiness of the voice may occur which gives a quavering intonation to speaking. Tremor of the trunk and legs is seen in some patients.
Tremor Surgical Treatment
Thalamic Deep Brain Stimulation is very effective in controlling tremor. In this surgery electrode is intorduced into VIM nucleus of thalamus and later on they are connected to pacemaker(IPG). The device can be switched off when not required.
In this surgery thermocoagulation is made at VIM nucleus of thalamus. This surgery abolishes contralateral tremor.
Millions of people suffer in silence affected by a disorder that affects about 2% of the population. Obsessive Compulsive Disorder (OCD) patients have a tendency to keep the disorder secret, suffering for months or years because they feel too humiliated or do not wish to be considered mad. Surveys have shown that it is not that rare a condition-it is the fourth commonest psychiatric illness.
Post of interview OCD patient after DBS
Obsessive Compulsive Disorder (OCD)
Typically a person with obsessions has repetitive thoughts, urges or images which cause a lot of anxiety (tension) to the individual. He recognizes these as senseless and unsuccessfully try to resist them. Compulsions are behaviours that are performed to lessen anxiety that is a result of particular obsessive thoughts.
The common obsessions are fear of dirt and contamination by germs; sexual and aggressive images or thoughts towards a family member; doubts of having left a task incomplete; hoarding useless things as they may have value in the future; need to have things perfectly in symmetry and order; evil and sinful thoughts and urges. Common compulsive behaviours are cleaning and washing, checking, arranging things in an orderly manner, counting or doing things in a certain number .25% all OCD patients became refractory after few years and will require DBS therapy
Role of DBS for OCD
For intractable OCD who are not responding to medication, DBS is very effective. symtoms over 60-70% improve and medication is slowly reduced over period of time. Anterior capsular along with nucleus acumbens stimulation is done that improves all the symptoms of OCD.
Mrs. Shakila KHan is a 48 year old housewife resident of Delhi Ph. 09953478912
Had OCD fort 20 years with the fear that she will be contaminated by drain water. She seeks reassurance frequently from her husband and frequently washes herself. Her husband has to open and close taps as she thinks they are contaminated. She used to remain in toilet for 6-7 hours. When her husband and son go out of the house she sits immobile at home, she does not cook, eat or even go to the toilet as she fears contamination. Cooking is an elaborate ritual where she orders her son to do the various chores and makes him wash any utensils she touches. The family frequently eats food from outside. She could not get benefit from multiple medications and her illness was rated as extreme. Deep brain stimulation was done in Dec 2010. She responded very-well after stimulation with all her symptoms improved in one month time. She started going to market, washing compulsion reduced considerably and she started cooking also. As per her she had 70-80% improvement in all her symptoms. Her improvement continued till 18 month after surgery and then again her symptoms started. Her pacemaker was checked and battery was found to be depleted. New pacemaker was replaced that lasted for 2 years. Recently in month of Nov 2016 medtronic rechargeable pacemaker was replaced for long term use.
Presently she has 60-70% improvement in her symptoms of OCD
J.K 45 years old married female resident of New Delhi PH 09899131027, 09910192828
Had intractable OCD. Her symptoms started when she was 19 years old. Her main obsession was for dirt, germs and white liquid. She was frequently washing herself and had checking compulsion also. Her illness gradually progressed. Initially she responded to medications but slowly response to medications declined. These symptoms were progressed gradually to indecisiveness, there was frequent fight in family and she used to remain in toilet for many hours. She tried to commit suicide but was revived. After her marriage there was frequent argument with her husband and her symptoms worsened after delivery. She could not get benefit with anti obsession medications and cognitive and behavioural therapy. She was operated on 12th July 2013. Deep brain stimulation in ventral striatum and anterior limb of internal capsule was done. Medtronic Activa RC (Rechargeable Impulse Generator) was used. She responded very well to stimulation. Her symptoms of obsession for cleanliness have improved and after follow-up of three years she has shown 70% improvement in her symptoms of OCD