10/13/2017. Disclosures. Deep Brain Stimulation in the Treatment of Movement Disorders. Deep Brain Stimulation: Objectives.

Transcription

1 Deep Brain Stimulation in the Treatment of Movement Disorders Disclosures None Eleanor K Orehek, M.D. Movement Disorders Specialist Noran Neurological Clinic 1 2 Objectives To provide an overview of deep brain stimulation (DBS) therapy To review general characteristics of Essential tremor (ET), Parkinson Disease (PD) and Dystonia To discuss indications for treatment with DBS therapy for ET, PD, and dystonia Deep Brain Stimulation: high frequency stimulation applied to specific targets 3 4 US FDA Approvals US FDA Approvals MEDTRONIC SYSTEM Tremor 1997 Parkinson s Disease 2002 Primary Dystonia 2003 through Humanitarian Device Exemption ST. JUDE MEDICAL Approved in 2016 for use in Parkinson disease and Essential tremor BOSTON SCIENTIFIC Their DBS system currently in trials 5 6

2 DBS system DBS System Unipolar Spherical field Bipolar More focused field + DBS Surgery Unilateral or bilateral Most surgeries done when patient is awake Microelectrode recording Intraoperative stimulation testing Staged surgery STAGE 1: Lead placement Small burr holes Local anesthesia Stay overnight in hospital STAGE 2: IPG placement 1 week later General anesthesia Same day surgery DBS Surgery Complications: Typically within 30 days of surgery Out of 1333 leads placed: Intracranial hemorrhage symptomatic 1.1%, asymptomatic 3.9% Seizure 0.3% Infection 1.7% 9 10 Post-Operative management Initial programming 1 month after surgery Benefit depends on: Lead location Optimized stimulation parameters Medication adjustments in PD Typically unable to stop meds entirely Deep Brain Stimulation: IMPORTANT UPDATE: MRI body NOT contraindicated if meet criteria and done with specified protocol for Medtronic DBS system Contraindications: Diathermy Electrocautery used with caution Defibrillation use if necessary, place pads far away as possible 12

3 Parkinson Disease: Overview Parkinson Disease: History Affects over 1 million in US, 10 million people world wide About 60,000 diagnosed each year in US Most commonly affects people over 60 Young onset PD diagnosed age 50 and under Higher incidence in men 1.5:1 Second most common neurodegenerative disease, second to Alzheimer s disease Described in ancient Indian medicine Ayurveda, called Kampavata First described in Western Medicine AD 175 by Galen as shaking palsy 1817 James Parkinson wrote An Essay on the Shaking Palsy 1879 Jean Martin Charcot named disease after Parkinson Clinical Presentation: Rest tremor 4-6 Hz Bradykinesia Decreased facial expression Impaired dexterity, slowed finger/toe tapping Decreased arm swing Shuffled gait Decreased automatic movements: blinking, swallowing, gesturing Clinical Presentation: Rigidity Increase in intrinsic muscle tone Postural changes Stooped/flexed posture Loss of postural reflexes Freezing Gait Speech Parkinson Disease - Bradykinesia Nonmotor Symptoms: Cognitive Slowed processing (Bradyphrenia) Subcortical Dementia Behavioral Apathy, Anxiety, Depression, Compulsions, Hallucinations Sleep Disorders 17 18

4 Nonmotor Symptoms: Treatment Options Autonomic Orthostatic hypotension Urinary frequency, urgency Constipation Pain/Sensory Studies show increased sensitivity to pain in patients with PD Exercise!! Physical, Occupational, Speech Therapies BIG and LOUD therapy Medications primary goal to increase dopamine/act on dopaminergic pathways Deep Brain Stimulation 19 Levodopa-induced dyskinesia Who s a candidate? Good response to carbidopa/levodopa Having fluctuations in response to medication Early off times Require increasing doses of medications Dyskinesias or other med side effects Typically at least 5 years into disease DBS for PD PRESURGICAL WORK UP ON/OFF testing with UPDRS >30% improvement Now going to go through CKRI for this Neuropsychological assessment MRI brain if not done within past year DBS for PD Absolute Contraindications : Dementia Atypical parkinsonism Relative Contraindications: Severe psychiatric condition Severe disability even in ON state Symptoms not relieved by levodopa Significant cerebral atrophy or white matter disease Severe comorbidities Advanced age - >75y older proceed with caution 23 24

5 EARLYSTIM trial led by Deuschl NEJM 2013 OMT vs DBS+OMT Average duration of disease 7.5 years, all under 60y 24 month follow up 26% improved PDQ-39, worsened by 1% in OMT group UPDRS-III scores) improved by 53%, 16 point difference in UPDRS at 24months (P<0.001) Two targets Globus Pallidus interna (Gpi) and STN Effectiveness Symptoms that respond tremor, bradykinesia, rigidity UPDRS scores improve 40-60% Disabling dyskinesias reduced 60-80% Reduced OFF time by about 60% Medication reduction 30-40% on average Symptoms that do not typically respond: Postural instability Speech Non-motor symptoms Cognitive impairment DBS for PD Study 5-year study DBS Therapy improved OFFmedication scores for: Tremor Rigidity akinesia/bradykinesia DBS for PD Essential Tremor Incidence 4% to 5% of people age 40 to 60 have ET. The incidence rate for people age 60 and older is estimated at 6.3% to 9% Estimated 10 million in US have ET Tremor that occurs with action > rest Strong familial component 29 30

6 DBS for ET DBS for ET VIM nucleus target Who s a candidate? Persistent tremor despite best medical management Meds either stop working or side effects intolerable Similar contraindications to PD patients Dementia Severe comorbidities Advanced age Dystonia Dystonia focal onset Sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both Typically patterned, twisting, and may be tremulous Often initiated or worsened by voluntary action Associated with overflow muscle activation Focal, segmental, generalized Younger patients tend to develop generalized dystonia Older patients develop craniofacial dystonia Dystonia First described by Oppenheim in 1911 Initially thought more psychiatric disorder 1970s Stan Fahn and David Marsden convincing case for dystonia neurological disorder Overall prevalence 164 per 1 million Excessive motor output from basal ganglia Loss of surround inhibition Abnormal somatosensory integration Dystonia - Treatments Botulinum toxin Most widely used Medications Anticholinergic (trihexyphenidyl, benztropine), antispasmodics (baclofen, tizanidine), benzodiazepines Physical therapy Massage Acupuncture DBS 35 36

7 DBS for Dystonia DBS for Dystonia Bilateral Globus Pallidus interna for chronic, intractable (drug refractory) primary dystonia Generalized dystonia, segmental dystonia or cervical dystonia 7 years of age or older References Fahn, S. Jankovic, J. Hallett, M. Principles and practice of Movement Disorders. Elsevier, Inc DBS patient in frame picture: Youtube, Patient Guide to Deep Brain Stimulation (DBS) Surgery, Mayfield Clinic Newby, R, et al. A History of Dystonia: Ancient to Modern. Movement Disorders Clinical Practice. May 22, 2017, Pp Albanese, A, et al. Phenomenology and Classification of Dystonia. Mov Disord, 2013 Jun 15; 28(7): DBS for Movement Disorders picture. Fasano A, Daniele A, Albanese A. Treatment of motor and non-motor features of Parkinson's disease with deep brain stimulation. Lancet Neurology 2012;11(5): Steeves TD, Day L, Dykeman J, Jette N, Pringsheim T. The prevalence of primary dystonia: A systematic review and meta-analysis. Movement Disorders 2012;27(14): Weaver FM, Follett K, Stern M, Hur K, Harris C, Marks WJ Jr, et al. Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA 2009;301(1): Fenoy, A. et al. Risks of common complications in deep brain stimulation surgery: management and avoidance. Journal of Neurosurgery, Jan 2014 / Vol. 120 / No. 1 / Pages Schestatsky, P, et al. Neurophysiologic study of central pain in patients with Parkinson disease. Neurology Dec 4;69(23): Deuschl, G. et al. Neurostimulation for Parkinson's disease with early motor complications. N Engl J Med May 23;368(21):2038 Questions? Eleanor K Orehek, M.D. Movement Disorders Specialist Noran Neurological Clinic (612)