At Aster Medcity, we offer you advanced Deep Brain Stimulation (DBS) therapy with comprehensive support services to help you regain your pace of life. DBS Therapy at Aster is led by a team of expert neurologists and nursing staff.Read More
At Aster Medcity, we offer you advanced Deep Brain Stimulation (DBS) therapy with comprehensive support services to help you regain your pace of life. DBS Therapy at Aster is led by a team of expert neurologists and nursing staff.
The following are the features of the DBS procedure at Aster Medcity for people having Parkinson’s disease and suffer from loss of movement due to the same
- Dedicated unit for extended and customized medical examinations
- Pre—operative management of medication and preparation
- Deep Brain Stimulation (DBS) neurostimulator’s functional testing
- Rehabilitation clinic
- Regular aftercare and follow-up care
- Round-the-clock support from Neurologists
Dr. Dilip Panikar
Dr. Boby Varkey Maramattom
Dr. Sujith Ovallath
Consultant-Neurology & Movement Disorder Specialist
1. Team of experienced expertise include the surgeon who performed first DBS surgery in INDIA
(Neurologist, neurosurgeons, Imaging & lab technologists, rehabilitation therapists & counsellors)Read More
1. Team of experienced expertise include the surgeon who performed first DBS surgery in INDIA
(Neurologist, neurosurgeons, Imaging & lab technologists, rehabilitation therapists & counsellors)
2. Advanced imaging facilities on campus which help our surgeons map the affected centres and plan the surgery in minute detail.
3. Dedicated surgical suites, equipped with stereotactic surgical equipment.
4. Dedicated supportive and follow up care for Post-operative patients
5. Support group for Post DBS patients. (PUNARJEEVAN)Read less
News & Events
Aster Medcity launches DBS Support Group for Parkinson’s patients
Kochi: Aster Medcity has launched a Deep Brain Stimulation (DBS) Support Group for Parkinson’s patients. DBS is a neurosurgical procedure involving placement of neurostimulator for the treatment of movement disorders, including Parkinson’s disease.Read More
Frequently Asked Questions
What are movement disorders?
A movement disorder is a condition that arises in the brain and causes unwanted, excessive movements or results in a loss of ability to move as much as a normal person or move with normal speed. The different abnormal movements are shaking (tremor), stiffness of muscles, slowness and loss of balance (parkinsonism), twisted postures (dystonia) abrupt jerks (myoclonus), dance-like flowing movements (chorea) and stereotyped rapid jerks and involuntary sounds (tics). Many diseases that produce movement disorders result from degeneration of brain cells in areas controlling movement and do not have an obvious cause or may be due to a genetic change. These movements can develop as a consequence of injury, infections, inflammation, metabolic disturbances and tumours of the brain or as side effects of certain drugs. Neurologists who are specialists in movement disorders can offer diagnosis and treatment for such conditions through dedicated movement disorder clinics.
What is DBS? How does it work?
DBS involves delivering small amounts of electricity via 2 thin electrodes (one on each side of the brain) which are introduced through 2 small holes in the skull and implanted into a specific target area deep in the brain. This procedure called stereotactic neurosurgery is different from conventional neurosurgery in which the brain is exposed and handled. The source of the electric current delivered, is a sophisticated pacemaker-like device (implantable pulse generator or IPG) implanted under the skin of the chest, below the collar bone. The IPG is connected to the two electrodes within the brain through an extension cable passing under the skin of the neck and behind the ear. Several software packages are available to plan electrode targets and trajectories on brain MRI of the person. The accuracy of targeting is confirmed prior to implantation of the DBS electrode by the movement disorder specialist, first by recording characteristic firing patterns of brain cells in the target area using a procedure called microelectrode recording. This is followed by a test stimulation to assess the benefits or any unwanted effects of electrical stimulation in that location. Once the location is confirmed, the DBS electrode is implanted in the same spot. In the days to weeks following DBS surgery, the movement disorder specialist will select the appropriate current settings in the implanted IPG that will provide the best clinical benefits to the patient. This procedure is called programming. It may need a few programming sessions in the first 3-6 months to identify the best stimulation settings for an individual. Thereafter clinic visits can be annual, to check battery settings, battery life and for adjustment of drugs.
Which are the conditions treated by DBS?
DBS is a recommended treatment for Parkinson’s disease, Essential Tremor and Primary generalized dystonias. It has also shown success in some forms of secondary dystonias and Tourette syndrome, when these diseases are not well controlled by drugs alone. The most common condition for which DBS is used is Parkinson's disease (PD). DBS does not cure any of these diseases but reduces the severity of the abnormal movements and improves the quality of life of persons affected by these diseases.
What is Parkinson’s disease? When is DBS performed in Parkinson’s disease?
PD is a progressive neurological disease caused by degeneration of nerve cells in an area in the brain called the substantia nigra. It is a part of the basal ganglia circuit that controls movements. The cells in substantia nigra produces an important chemical called dopamine required for the normal functions of the basal ganglia circuits. Parkinson's disease patients experience the typical motor symptoms of tremor at rest, stiffness of the limbs, slowness of all activities and later poor balance in varying combinations. It is now well established that a number of non-motor symptoms occur in PD such as depression anxiety, cognitive changes, sleep disturbance, urinary urgency, constipation, pain, slurring of speech etc. It is estimated that about 7-10 million people have the disease world -wide and about 60,000 new cases are diagnosed each year. While the risk of a PD increases with age (average age of onset in the early 60s), around 5-10 percent develop the symptoms before the age of 50 and about 1-2 % have other family members affected by the same condition.
How is PD treated?
PD is not curable. PD is initially treated with medicines that relieve the symptoms and enable them to function well. Levodopa and other dopamine replacement medications have been used since the 1960s and gives excellent relief the first 3-5 years of treatment. With the progression of the disease and changes in the brain, the beneficial effects of levodopa wane and symptoms of patients fluctuate through the day. These motor fluctuations can be a predictable early wearing off, of the benefits of a dose of levodopa or a delayed response to levodopa or sudden unpredictable loss of effect of levodopa. Levodopa can also induce dyskinesias which appear as involuntary dance -like flowing movements in the neck, trunk, or limbs. These complications occur in most, if not all patients during the course of the disease, usually within 5-10 years.
What is the role of DBS in PD?
DBS in PD is recommended for patients (1) experiencing motor symptoms fluctuations with or without dyskinesias (2) tremor unresponsive to drugs and (3) who cannot tolerate high doses of drugs. Recent studies have shown that patients with mild to moderate fluctuations or dyskinesias benefit as much as those with more advanced disease and early referral is indicated. Long-term results of DBS have shown significant improvement in (1) the motor symptoms of PD (2) the ability to perform activities of daily living independently and (3) the quality of life of patients.
DBS performed in two target areas in the basal ganglia (STN and GPi) is equally effective in PD. Following DBS in the STN, the doses of levodopa can be reduced in most patients, thus alleviating dyskinesias caused by levodopa.
Previous reports show that motor function was significantly improved after STN DBS, by 25–60% in the “off” medication state after STN DBS, patients were able to reduce dosages of dopamine replacement medications by approximately 50%. Non-motor symptoms of PD did not improve among patients treated with STN DBS. Several studies have assessed the long-term efficacy at 5-year and 10-year time points after DBS. These studies indicate that STN DBS has continued positive benefits and persisting improvement in motor scores and in quality-of-life assessments.
Are the benefits of DBS predictable?
- Individual patient outcomes depend on several factors, including age, patient selection, target selection for implantation, accuracy of electrode location, programming settings, adjustments in medicines following DBS.
- Symptoms of PD that improve with levodopa, improve after DBS. The only exception is tremor which responds to DBS, even if it is not relieved by levodopa.
- Partial or incomplete response to DBS in PD patients may be partly due to incorrect patient selection or suboptimal DBS electrode placement.
- Unrealistic expectations from DBS can also result in patients being dissatisfied with the treatment.
- A critical factor influencing successful outcomes for DBS is a multidisciplinary team that specializes in the care of patients with DBS devices. The typical team includes a movement disorder specialist, a neurosurgeon who has a specialty training in stereotactic and functional neurosurgery and a neuropsychologist who has knowledge and experience assessing cognitive, mood and behavioural changes in PD. Patient outcomes are better when DBS surgeries are performed regularly by the team in high volume centres.
- Device programming and management of medications following DBS are better when provided by an experienced movement disorder specialist.
How are patients selected for DBS in PD?
Proper selection of patients is critical to success. This requires careful evaluation by a movement disorder neurologist, a neurosurgeon, a neuropsychologist, and a psychiatrist if needed. DBS is not for every PD patient and not for patients in the very advanced stage of the disease.
- The most suitable candidates are those with motor fluctuations and/or dyskinesias or those with tremor that does not respond satisfactorily to levodopa. Even if severely disabled when the effect of medicines wear off (OFF state), in the ON state while experiencing the best effect of levodopa, the person should be able to walk independently, should not have falls or freezing of gait and their speech problems should be minimal.
- Current evidence shows that it is not necessary to wait till motor fluctuations and dyskinesias become disabling and patients offered early DBS do better than the best available medical treatment.
- The cognitive, psychiatric, and behavioural status must be normal or only minimally affected. Patients with dementia and severe depression are not offered DBS.
- Patients have no other serious medical conditions.
- There are no strict age limits for DBS. The ideal profile is a patient with young- onset PD (onset under 50 years) and aged less than 70 years at the time of surgery. Most patients who undergo DBS may not fit the ideal description but an experienced movement disorder neurologist can make a medical judgement of the extent of improvement that can be anticipated and whether the deviations from ideal scenario can be considered acceptable. Recent reports show that patients older than 70 years have no increased surgical complications and can benefit from DBS.
- Finally, patients and their family have to make their own decision based on the detailed information of their individual risks and potential benefits of DBS. Patient expectations, cooperation, and familial support are important considerations while selecting patients for DBS. They should understand that DBS is not a cure but only a supplementary treatment and does not replace the medical therapy. It improves only the motor but not the non-motor symptoms of PD.
What are the risks of DBS?
These are potential risks for DBS surgery, though low (1-2%), of complications during the implantation (bleeding in the brain causing stroke, infection, malposition of electrodes, or unsatisfactory trajectories and abandonment of procedure) or during long-term care (hardware failure, extension cable breakages). Spread of current to neighbouring structures can produce unwanted effects such as diplopia, slurring of speech etc which are reversible on reducing the current but may indicate that electrode is not in motor area within the target. Reduction in verbal fluency has been noted in many patients following STN DBS. Depression, and worsening of gait and falls have also been reported soon after DBS.
What are the preparations for DBS?
Patients who are at increased risk of perioperative complications should be optimized on medicines before surgery is planned.
A. Persons with a history of heart disease should be evaluated by a cardiologist and those taking antiplatelet drugs for heart disease or anticoagulants must temporarily stop taking these medications prior to surgery or bridged with short acting anticoagulants.
B. Hypertension and diabetes should be adequately controlled.
C. Depression, impulse control disorders and anxiety to be treated before surgery.
D. Surgery is most commonly performed while the patient is awake and should be able to co-operate for assessment of benefits and side effects of test stimulation during surgery. If this is not possible, DBS can be done under general anaesthesia.
E. Appropriate counselling of the patient and family.
DBS was first approved by the U.S. Food and Drug Administration (FDA) for Parkinson's tremor in 1997 and then for other Parkinson's symptoms in 2002. Medtronic was first on the market and remained the only DBS device maker for over a decade until additional devices, including the Abbott St. Jude Infinity and Boston Scientific Vercise, gained approval in the last few years.
Which IPG to choose -rechargeable battery or fixed life battery?
The life of a non-rechargeable or fixed life battery (IPG) is approximately 3-5 years
(depends on individual patient’s current usage) and will need to be replaced, while the rechargeable ones can last 15-25 years and therefore fewer replacement surgeries.
Rechargeable batteries require daily or weekly recharging. Some patients prefer regular recharging for the advantage of fewer battery replacements while others prefer 5 yearly battery replacement to regular recharging. Rechargeable batters are almost twice as expensive as the non-rechargeable ones.