Deep Brain Stimulation and pump placement
Significant developments have been made in recent years in the treatment of Parkinson’s disease. The interventional methods being used these days include Deep Brain Stimulation (DBS) and placement of continuous infusion pumps (Apo-Go or Duodopa).
A patient that has had Parkinson’s disease and motor fluctuations for at least five years may be examined by the interventional clinic’s multidisciplinary team for treatment of Parkinson’s disease, so that the most suitable method can be chosen that will improve the patient's quality of life with minimal risk, while relieving their carer’s burden.
The multidisciplinary team consists of a neurologist, a neuropsychologist, a neurosurgeon and a gastroenterologist.
ΤΙ ΕΙΝΑΙ Η ΑΝΤΛΙΑ ΣΥΝΕΧΟΥΣ ΕΓΧΥΣΗΣ DUODOPA
Η αντλία DUODOPA είναι μια φορητή αντλία συνεχούς έγχυσης που παρέχει υγρή ντοπαμίνη στον ασθενή, μέσω ενός λεπτού καθετήρα που καταλήγει στην κοιλιά του και συγκεκριμένα στον δωδεκαδάκτυλο, όπου γίνεται και η απορρόφηση της ντοπαμίνης. Αυτό εξασφαλίζει σταθερότερη απορρόφηση και ομαλότερα επίπεδα ντοπαμίνης στο αίμα. Η αντλία είναι φορητή και προσφέρει μεγάλη αυτονομία κίνησης στον ασθενή ο οποίος μπορεί να συνεχίσει τις καθημερινές του δραστηριότητες.
WHEN IS IT TIME FOR SURGERY
Basic selection criteria
Surgical treatments for Parkinson's disease are not performed on end-stage patients. They must be performed at the right time, so that falls, fractures, bed rest and disability are avoided, and the independence of the patient and their family is achieved.
The time is right when the patient has one of the following symptoms:
- Severe difficulty in everyday tasks because of disease-related hyperkinetic movements or frequent ON/OFF fluctuations
- Dopamine has a good effect on motor symptoms
- Frequent use of dopamine (four or more times a day)
- Absence of mental diseases or severe dementia
- Supporting environment
- Biological age of up to 70 years for the neurostimulator, while pumps do not have an age limit
Particularly for the neurostimulators and according to the EARLYSTIM study that was published in N Engl J Med in 2013, neurostimulator implantations must be done early on in the disease. That is, when the disease has just started to make the patient’s life difficult. This study showed that patients that underwent surgery just two years after the motor fluctuations began had a 26% improvement in the quality of their lives compared to patients who continued their treatment regimen. This rate was maintained throughout the study, which shows that the earlier one undergoes surgery, the more they will maintain the quality of their life. Naturally, patients with neurostimulator implants also demonstrated an impressive improvement in other aspects, such as motor fluctuations, ON/OFF phenomena and more.
The multidisciplinary committee decides whether a patient is suitable for surgery.
DBS NEUROSTIMULATOR IMPLANTATION PROCEDURE
Patient’s suitability check-up
In order to determine whether a patient will benefit from the implantation of the neurostimulator, they must undergo a thorough check-up. This check-up may be carried out either during a three-day hospital stay or on an outpatient basis. A multidisciplinary meeting is then held in the presence of the neurologist and neurosurgeon and it is decided if the patient is suitable for the procedure and how much they will benefit from this.
The check-up includes:
- A neurological examination is performed and the patient’s history is taken to verify that the patient is at a suitable stage and that they no longer benefit from drugs or another procedure.
- LDOPA test (one-day hospital stay). This is the most significant test that needs to be performed on a patient who wishes to undergo DBS. During this test, the patient stops taking medication from midday before the day of the test and for 12 hours. The next morning they are examined in the worst OFF motor state (best OFF). They are then given a specific amount of dopamine and are examined in the best ON motor state (best ON). For the patient to be suitable for neurostimulator implantation, the improvement between best OFF and best ON must be greater than 50%. In practice, this means that after surgery, the patient is expected to be on the best ON motor state throughout the entire day without motor fluctuations, such as hyperkinetic movements or immobility. The test lasts about 2-4 hours.
- Neuropsychological examination of higher cognitive functions and sphere of mental health by neuropsychologist/psychiatrist. It is performed with structured questionnaires. The examination lasts about three hours.
- MRI of the brain (may be provided by the patient).
We treat Parkinson’s disease with the most suitable method in order to improve your quality of life.
HOSPITALIZATION AND FOLLOW-UP FOR DBS NEUROSTIMULATOR
The implantation of the finest stimulation electrode is performed with precision in the operating room, with the use of a stereotactic frame by a neurosurgeon and neurologist. Three-dimensional magnetic resonance imaging and a contemporary atlas are used to localize the target region. The procedure lasts about 4 hours. The patient can get out of bed the next day.
After the procedure, the patient remains in hospital until the neurologist performs:
- Detailed recording of the neurostimulator abilities and restrictions
- Customization of the neurostimulator settings
- Reduction of the drug regimen
Hospitalization ranges between 7 to 15 days and depends on the severity of the disease and the patient’s age. Our objective is for the patient to move autonomously and comfortably without motor fluctuations when leaving the hospital.
Following the procedure and for a period of three months the neurostimulator settings will need to be adjusted by the neurologist on an outpatient basis. The adjustment visit lasts about 1-2 hours. It can take place every 10-15 days. After the first six months, follow-up is done annually.
EFFECTIVENESS OF THE DBS NEUROSTIMULATOR METHOD
The success of the DBS depends exclusively on:
- The stage of the disease. According to the EARLYSTIM study in 2013, “the earlier, the better”
- The correct patient choice and their individual LDOPA TEST score
- The successful placement of the electrodes
- The adjustment of the neurostimulator settings that are customized for each patient
- The patient’s compliance to the doctor’s orders
After the LDOPA TEST performed for the suitability check, the patient knows the improvement rate after the procedure. In general, according to international literature, it offers an average improvement of 73% in motor symptoms, a 58% reduction in the drug regimen and a 67% reduction in dyskinesia. This means that a 55-year patient who may risk losing their job can continue working, or a 65-year-old can continue enjoying life without the disease’s disabilities and restrictions. These results last for at least a decade. Besides the improvement in all aspects of the disease, this method provides the patient with independence because the neurostimulator is placed under the skin, just like the heart pacemaker.
The DBS provides the patient with independence because it is placed under the skin, just like the pacemaker.
DUODOPA PUMP PLACEMENT PROCEDURE
Patient suitability check-up:
- A neurological examination is performed and the patient’s history taken as a first step to verify that the patient is at a suitable stage and that they no longer benefit from drugs or another procedure.
- Then, to determine whether the pump will help with the patient’s symptoms, a three-day inpatient trial period is required, at which time the patient will receive liquid dopamine via the pump with an external nasoenteric tube. Its placement is simple and painless and takes 15 minutes. Other medication is discontinued. During the trial period, the patient becomes familiar with the pump, while the exact dose of the liquid dopamine, which is required to keep the patient in a peak motor state throughout the day, is adjusted. PARKINSON CARE offers free daily nursing care on a 12-hour basis with a qualified nurse, who will explain how to administer the drug, how to use of the device and how to maintain it. On day 3, the patient goes home wearing the pump. The aim is for the patient to live with the pump in their home environment, so that they may see whether the results significantly improve their everyday life. Thus, they will have a better feel of the benefits and whether they want to move onto the final placement of the pump.
- At a later stage, provided the patient has experienced a significant improvement in their home life, a multidisciplinary meeting is held before the neurologist and gastroenterologist, and it decided if the patient is suitable for the procedure and how much they will benefit from this.
Free daily nursing care on a 12-hour basis by PARKINSON CARE
HOSPITALIZATION FOR INSERTION OF THE DUODOPA PUMP AND FOLLOW-UP
Insertion of the final tube requires one-day hospitalization. The procedure for insertion of the final tube lasts about 45 minutes and is performed under light sedation. A PEG is essentially performed and a thin tube is inserted up to the duodenum, the part of the intestine that is located immediately after the stomach. Dopamine is absorbed from the duodenum.
Thus, the patient receives the exact amount of dopamine in exactly the area where it is absorbed. This ensures steady absorption and balanced dopamine levels in the blood, avoiding excess drug complications. The tube can be removed without surgery if the patient so desires.
The patient’s follow-up is done in two ways:
- A re-examination will be required in 7 days and then after a month by the neurologist. Then every six months.
- By the qualified nurse from PARKINSON CARE, who visits the patient at home for free. These visits are scheduled once a month; however, they can be arranged on an exceptional basis. PARKINSON CARE also has a 24-hour DUODOPA hotline - +3021088830043
EFFECTIVENESS OF THE DUODOPA PUMP
In accordance with international literature, the results are similar to those of the neurostimulator. According to Devos et al MD 2000, it shows improvement in motor fluctuations by 96%, in dyskinesia by 94.7%, in pain by 74.7%, in gait disorder by 61.4% and in dysphagia by 60%. Many studies report improvement in non-motor symptoms. Furthermore, the advantages of this method are that it is less invasive, there is no age restriction and it is easily reversible.
According to Devos et al MD 2000, it shows improvement in motor fluctuations by 96%, in dyskinesia by 94.7%, in gait disorder by 61.4%, in pain by 74.7% and in dysphagia by 60%
PARKINSON CARE also has a 24-hour DUODOPA hotline: +30 210 883 0043
PARKINSON’S DISEASE UNIT
Nikolaos Chaliasos, Neurosurgeon - +30 210 480 9406
Zikos Panagiotis, Neurologist
CALL DAILY 09:00-15:00 ON:
+30 210 480 9406 for the Interventional Clinic for the Treatment of Parkinson’s Disease
9 Ethnarchou Makariou & 1 E. Venizelou Streets, 18547 Neo Faliro