A clear understanding of DBS for Parkinson’s disease

What is Deep Brain Stimulation (DBS) and how does it work?

Deep brain stimulation (DBS) is a medical technique through which electrodes are implanted in the brain and electrical impulses are delivered to block or alter the irregular behavior that causes symptoms.

Four parts of the deep brain stimulation system

There are four components of the deep brain stimulation system:

• Leads are thin insulated wires that terminate in electrodes implanted in the brain.
• A pulse generator is a small pacemaker-like system that generates electrical pulses.
• Extension leads bind to the leads implanted in the brain and brings electrical signals from the system.
• The hand-held programmer can change the device’s signals as well as switching it on and off.

Electrodes are mounted in the targeted areas of the brain during deep brain stimulation. Wires attach the electrodes to a pacemaker system (called an implantable pulse generator) that is implanted under the skin of the chest below the collarbone.

When the pulse generator is turned on, it sends constant electrical signals to the target areas of the brain, changing the circuits in those areas. The deep brain stimulation device works in a similar way to a heart pacemaker. Deep brain stimulation is often referred to as the “brain’s pacemaker.”

How Deep brain stimulation benefits a man with Parkinson’s disease?

Deep brain stimulation (DBS) sends electrical impulses to a specific region of the brain that is responsible for Parkinson’s disease’s movement symptoms (also known as motor symptoms). The electrical impulses interrupt the irregular behavior in the brain’s circuitry, which is the source of the symptoms.

Deep brain stimulation can be used to target three regions of the brain in Parkinson’s disease patients. The thalamus has three nuclei: the subthalamic nucleus, the globus pallidus internus, and the ventral intermediate nucleus. Each of these areas has a role to play in the circuitry of the brain that regulates movement.

In a person with Parkinson’s disease, the exact region of the brain to reach depends on the symptoms that need to be addressed. Deep brain stimulation of the subthalamic nucleus, for example, is useful for all main movement symptoms of Parkinson’s disease, including tremor, bradykinesia, stiffness (rigidity), and walking and balance issues. Another important target for a wide variety of Parkinson’s symptoms is deep brain stimulation of the globus pallidus. Patients with tremor symptoms are often given the thalamic target. The neurologist, neurosurgeon, and other caregivers involved in the decision-making process work to evaluate the recommended goal for each patient.

Three distinct components make up the DBS system:

The electrode, also known as a lead, is a thin, insulated wire that is inserted into a particular brain region through a small opening in the skull.

The extension wire, which connects the electrode to the internal pulse generator, is also insulated and passes under the skin of the head, neck, and shoulder (IPG).

The third part of the device is the IPG, which is normally inserted under the skin in the upper chest.

What is the risk associated with DBS?

DBS is safe and successful in patients who are appropriately chosen. There are risks and possible side effects, but they are usually minor and reversible.

The following are some potential risks:

• Brain hemorrhage, including stroke, is a 1% risk.
• Infection.
• Error in the system
• For certain symptoms, there is no benefit.
• Pressure in the head
• deterioration of mental or emotional health

Side effects that can occur during stimulation include:

• Tingling sensations in the face or limbs
• Muscles feel as if they are being ripped apart.
• Problems with speech or vision
• Loss of balance

Deep Brain Stimulation (DBS) for Movement Disorders Has Mental Side Effects

Deep brain stimulation’s advantages for parkinsonian patients have been well known, and the procedure has become a mainstay in the late stages of the disease. However, records of mental side effects were reported early in the method’s history. The latter’s outcomes are uncertain, with a trend toward less extreme side effects in a significant number of experienced centers. Acute effects weaning over a short time are largely blamed for adverse outcomes in this domain.

To counter such assertions, one might point out that, particularly in the case of complex psychiatric side effects, there is no reliable way of determining whether a treatment is a success or a failure. This is complicated further by the fact that PD is a disorder characterized by cognitive, affective, and behavioral symptoms, and therefore has a neuropsychiatric component. In certain cases, DBS might also be able to recover the original personality, which is then clearly no longer compatible with the actual social and familial environment. Finally, medication-based treatments for Parkinson’s disease may have serious neuropsychiatric side effects.

Nonetheless, a significant proportion of DBS patients continue to experience serious and long-lasting conduct disturbances that were ostensibly not present in the final preoperative process, prompting criticism. This includes risky driving and other types of risk-taking, as well as violent and contemptuous attitudes toward family members and spouses. Moving active contacts outside the STN may often alleviate this, with hostile activity subsiding within hours. This suggests that stimulation has a direct impact. Unfortunately, to relieve psychiatric symptoms in certain patients, stimulation must be significantly decreased or fully turned off. Numerous studies and case series have contributed to this problem by identifying troubling psychological disturbances ranging from hypomania to suicidal ideation and suicide, dismissing major improvements as unrelated to the overall quality of life, or even finding a significantly higher frequency of psychoses in the control group than in the DBS group.

Deep Brain Stimulation and psychiatric disorders

Mood and actions

Hypomania is a symptom that is mostly overlooked because of its rarity. Hypomania becomes dangerous when one’s ability to judge one’s own strengths and limitations are affected. Although the patient (and the surgeon) may be pleased with the outcome, the patient’s family may be concerned about the patient’s lack of inhibition and reckless behavior.

Hypomania may fade after a few weeks, but other mood and behavior changes may emerge. Depression and apathy may grow over time, resulting in a substantially decreased quality of life for both the patient and his caregivers.

Suicide is a form of self-destruction

While some research finds substantially higher rates of suicide, a recent prospective study found no direct correlation between DBS surgery and suicide. Suicide after DBS has occurred not only with various anatomic targets but also with diseases other than Parkinson’s disease, complicating the situation further. Suicide is a rare occurrence that is statistically difficult to assess; however, it is concerning that these incidents occur even in prospective studies with near-patient supervision. The situation remains perplexing from a layperson’s perspective; patients and their families are concerned due to news of certain incidents in inpatient representative bodies that seem to contradict research and expert opinions.

Personality and moral integrity

While hypomania fades and depression may lead to medication, measurements are rarely taken to rule out less apparent behavioral and personality changes. Recent major studies have found no evidence of changes in personality or moral integrity. One explanation may be that they’re difficult to weigh with the scales on hand right now. Scales that rely on the patient’s awareness are doomed to overlook deficiencies in his ability to deal with the needs of others. To follow scales and expertise, collaboration with experts in the field of moral psychology should be considered.

STN

The activated aim may be one explanation for the high level of psychiatric side effects. The STN must be scrutinized first and foremost because it is the normal target for DBS in Parkinson’s disease.

The assumption that the STN consists of three clearly divided sections and that electrodes can be reliably steered into the motor portion, which only contains motor functions, is one of the essential assumptions in defense of the STN’s protection. Furthermore, since the assumed motor division is minimal, currents from the currently used electrodes would almost certainly spread to other areas of the brain, including the limbic subdivision.

Our Take

Dr. Adil Moulanchikkal, a specialist in the treatment of Parkinson’s disease and other movement disorders, sticking to the fact that such treatments are only for a few selective people who can afford to try them out and that they are not hoping for long-term results of improved quality of life.

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