Coastal Neurological
Medical Group, Inc.

Deep Brain Stimulation - Subthalamic Nucleus
Are you a candidate for DBS?
BY DEE E. SILVER M.D.

The ideal patient for Deep Brain Stimulation{DBS} is a patient who had Idiopathic Parkinson's disease and is L-dopa responsive. Patients with atypical Parkinson's disease would not be a candidate. A patient with idiopathic Parkinson's disease that would respond the best would be a patient who has dyskinesias, fairly robust tremor and a fair amount rigidity and akinesia with asymmetry.

Younger patients are better candidates and in the large clinical trials most patients have been under the age of 70. However, if a patient is fairly healthy and does not have a great deal of comorbidity, patients over the age of 70, maybe even up to 75 or possibly 80, would be potential candidates. Patients should not have any neuropsychiatric symptoms such as vivid dreams, hallucinations, or delusions. There should be no cognitive impairment and it would be important to have a normal depression survey and a normal Mini-Mental State Exam. The ideal patient would not have any major comorbidity such as significant vascular disease or history of cerebrovascular or coronary vascular disease. The patient should have had a trial of all anti-Parkinson medicines. They should have had an ideal pharmacological adjustment so as to make the patient's symptoms as minimal as possible with medications and adjustments. Patients with prominent dyskinesias and/or tremor often improve the best.

Patients who have the Deep Brain Stimulation often improve dramatically in their activities of daily living and their locomotor scores, or UPDRS scores. In clinical trials motor score improvement can be as high as almost 50%. Reduction in dyskinesias can be dramatic and improved mobility without involuntary movement can be increased by up to 50%. OFF time is improved, ON time is improved and the L-dopa dose can be reduced by as much as 25-50%. Activities of daily living and quality of life scores are definitely improved in most cases. Subthalamic nucleus stimulation seems to be slightly more efficacious than globus pallidus stimulation.

Adverse events can be significant with intracerebral hemorrhages (1 to 2%), infections, seizures, hypophonia, and dysphagia all occuring. Wire and lead fracture certainly can occur as can infection and reduced skin healing. A major part of DBS is the programming of the device (IPG). This takes several sessions and considerable experience to arrive at an ideal clinical state for the patient.

Deep brain stimulation has been a major advance in the treatment of Parkinson’s disease. When the patient is selected correctly and is in the appropriate hands the patient has a great chance of having dramatic improvement in their activities of daily living and their quality of life.

Dr. Dee Silver and Dr. Ken Ott started the deep brain stimulation program at Scripps Memorial Hospital La Jolla over five years ago and have done numerous patients at the present time.

There have been about 60 procedures done and the results have been certainly consistent with the results of the trials and information mentioned above. There are other centers that are also doing DBS in Southern California. It is which patient that is selected that is likely to determine the likely complications of the DBS, cognitive changes, poor results and neurological complications. Hence the key is not only the patient selected but the neurologist and neurosurgeon.

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Coastal Neurological Medical Group
9850 Genesee Avenue
Suite 860
La Jolla, CA 92037
Tel: 858.453.3842
Fax: 858.535.9390

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