Surgical Management of Parkinson s Disease

Transcription

1 Surgical Management of Parkinson s Disease Shyamal H. Mehta MD, PhD Assistant Professor of Neurology, Movement Disorders Division Mayo Clinic College of Medicine Mayo Clinic, Arizona 2016 MFMER slide-1

2 Disclosures None relevant to this presentation 2016 MFMER slide-2

3 Surgery for Parkinson s Disease 1. Surgical Lesioning Thalamotomy, Pallidotomy, etc. 2. Deep Brain Stimulation GPi, STN, etc. 3. Surgery for Drug Delivery Duopa 4. Déjà vu Lesioning: Gamma Knife surgery MR guided focused ultrasound 2016 MFMER slide-3

4 Parkinson s Disease Treatment: Continuum of Interventions Disease Severity Mild Moderate Severe Patient Symptoms Signs of levodopa wearing-off Dyskinesia, On-Off Motor Fluctuations Postural Instability, Freezing, Falls, Dementia Treatment Agonists MAOI, amantadine Levodopa, COMT inhibitors, others DBS Modified from Giroux, ML and Farris, SF. Cleveland Clinic Foundation 2005 Cleveland Clinic Foundation Center for Neurological Restoration

5 2016 MFMER slide-5

6 Who is a good candidate for surgery? Diagnosis of idiopathic PD Responds to levodopa or dopaminergic tx Moderate to advanced disease Not too old (typically under age 75) Medically stable No significant cognitive decline/dementia Patient understands surgery will improve dyskinesias, tremor, bradykinesia, and rigidity, but probably not gait and balance 2016 MFMER slide-6

7 WHEN SHOULD DBS BE CONSIDERED? When, despite optimized pharmacotherapy, patient experiences troubling motor symptoms, which may include: Troubling dyskinesia Severe Motor fluctuations unpredictable off s Refractory tremor, Intolerant to meds EXCLUSION CRITERIA FOR DBS * Atypical (non-idiopathic) parkinsonism * Lack of sustained response to levodopa * dementia 2016 MFMER slide-7

8 DBS: Implantable Components Lead Extension Neurostimulator (implantable pulse generator) Activa SC Single Channel Output Activa PC & RC Dual Channel Output Medtronic DBS systems Most commonly used systems 2016 MFMER slide-8

9 New Players St. Jude Infinity Systems Boston Scientific Versice System 2016 MFMER slide-9

10 PROGRAMMING Voltage (0-10V) : usually 2-5V Frequency : Hz Pulse Width : µs Contacts : 0, 1, 2, 3 monopolar or bipolar 1.27mm 10.5mm 2016 MFMER slide-10

11 Rossi PJ et al. Front. Neurosci. 10:119. doi: /fnins MFMER slide-11

12 Directional DBS 2016 MFMER slide-12

13 Motor symptoms improvement after 10 years post-dbs Motor benefits apparent at 10 years significant improvement in tremor, bradykinesia, and total motor score. 18 patients STN DBS - Arch Neurol 2011;68: patients STN DBS - Mov Disord 2011;26: no longer improvements seen in Activities of Daily Living (ADL) Scores MFMER slide-13

14 Duopa Is a Different Way to Deliver Carbidopa and Levodopa A suspension form of carbidopa and levodopa continuously delivered over 16 hours by a pump through a tube in your intestine. Bypasses the stomach and intended to avoid the effects of slowed or delayed gastric emptying Delivered into the small intestine, where levodopa is primarily absorbed MFMER slide-14

15 Duopa In a clinical study, 71 patients with advanced Parkinson's disease with persistent motor fluctuations despite taking PD medications (including carbidopa-levodopa pills) took either Duopa or carbidopa-levodopa immediate release pills for 12 weeks. Off Time Reduced 4 hours with Duopa vs. 2.1 hours with Carb/Levo pills On time w/o troublesome dyskinesia increased 4.1 hours with Duopa vs. 2.2 hours with Carb/Levo pills The most common side effects of DUOPA include: complications of tubing placement procedure, swelling of legs and feet, nausea, high blood pressure (hypertension), depression, and mouth and throat pain MFMER slide-15

16 Mov Disord Mar 31. doi: /mds MFMER slide-16

17 MRgFUS Pro s Awake No anesthesia No insertion of electrodes Cons No longterm data Irreversible lesion, unilateral 2016 MFMER slide-17

18 Summary Deep Brain Stimulation - long track record - next generation techonology Duopa - no brain surgery - safe and efficacious Lesioning less optimal option 2016 MFMER slide-18

19 Thank you!!! For Consultations/Appts: Marie Baranowski MFMER slide-19