This past weekend, the California Association of Neurological
Surgeons and the Association of California Neurologists held a joint
meeting in San Francisco.  The talks on Sunday were devoted to
epilepsy and Parkinson's disease.  Some interesting material was
presented on PD which I will share with the List.

The first presenter was Stanley Fahn, M. D., from the Neurological
Institute of New York, and the Executive Director of the PD
Foundation.  He discussed the newer drugs for PD, including
Pramipexole and Ropinrole.  He pointed out how these drugs can
cause sudden "sleep attacks" (no warning) and how patients on these
drugs should not be allowed to drive.  He also discussed the
catecholamine inhibitors such as Tocapone and Entacapone, which
extend Dopamine effects but which can increase those side-effects as
well.  The "atypical antipsychotics" (Quetiapine is the best one) can
be helpful for some of the psychotic suymptoms, but Clozepine
requires very careful monitoring of blood counts.

Dr. Fahn then went on to describe a large study which utilized
transplants of fetal tissue.  The was a double-blind study which did
the evaluations in New York and the surgery in Denver (the patients
were transported).  A large placebo effect was noted (half of the
patients had "sham" operations; the ones who had the "sham"
procedures were later allowed to have "real" surgery).  The results
were better in younger patients (younger than age 60), and the
improvements were in the areas of bradykinesia (slow movement) and
rigidity.  Tremor and gait *did not improve*.  A small number of
patients *got worse* from excessive production of Dopamine by the
transplanted cells.  Over the long-term, there was progressive
improvement in the "off" state, but this was more pronounced in the
younger patients.  The dosage of Dopa drugs was reduced somewhat.
The summary of the study was:

1. The transplanted tissue survives (in about 2/3 of cases)

2. Transplants *increase* dyskinesias (worsening), especially in
young people.

3. Better analysis of patients needed.

4. "This method is not yet ready for treatment of patients"! (this is a
direct quote from Dr. Fahn)

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The second talk was by Dr. Gary Heit, neurosurgeon from Stanford
who is one of the prime people in the surgery of movement disorders.
He spent some time in Loma Linda in the past working with Dr. Robert
Iacono, of pallidotomy fame.  His criteria for accepting patients for
surgery include failure of medical treatment; no dementia (surgery
worsens dementia), no structural lesions before surgery; and
cooperative patients (deep brain stimulation surgery takes 6-9 hours).

Dr. Heit uses many different targets in the brain including parts of the
thalamus, pallidum (for dyskinesias and maybe dystonias), and
subthalamic nucleus.  He says that "the only indication for
pallidotomy is that of dyskinesias and/or some dystonias" and he
does not do pallidotomy for anything else.  He also says that
stimulation of the subthalamic nucleus can cause depression.

Dr. Heit believes that the future of this kind of treatment is in
*stimulation*, not "ablation" (pallidotomy, thalamotomy).  He uses
complex physiological mapping and has done 40-50 cases of deep
brain stimulation (DBS) with no major side-effects.

His outcomes show that the beneficial results of ablative surgery
(*used only for pre-treatment of dystonia*) seem to persist for at least
3 years, but pure Parkinson patients tend to develop dysarthria
(speech problems) after pallidotomy.  DBS appears to be "very
effective" for tremor (15 cases thusfar).  Bilateral implants (stimulators)
can cause slurring of speech, but can be "turned off" on one side
when this is a problem.

Stimulation in the subthalamic nucleus (STN) seems to be better for
PD than pallidotomy or thalamotomy.  It also seems to help the
akinesia (motor slowness) of PD.  He feels that pallidotomy patients
are beginning to "fail" after time (just like what happened back in the
sixties with the earlier attacks on the pallidum), and that patients who
have had pallidotomies are slowly returning with failures.  Dr. Heit
made the following quote:

"Pallidotomy is no longer indicated for Parkinson's disease"

I was very impressed with Dr. Heit and spent some time talking with
him after the meeting.  He is a young, extremely bright, friendly, and
affable young man, and I would suspect that his patients love him.


Best,

Bob Fink


**********************************************
Robert A. Fink, M. D., F.A.C.S., P. C.
2500 Milvia Street  Suite 222
Berkeley, California  94704-2636
Telephone:  510-849-2555   FAX:  510-849-2557
WWW:  http://www.dovecom.com/rafink/

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"Ex Tristitia Virtus"

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