This as seen on the park listserv on the internet;
 
 
 
I attended the "What's Best for Parkinson's Disease" symposium
 
March 29th in Tulsa, OK.
 
 
 
About 100 doctors and health care professionals attended
 
to hear about the latest strategies in medicine and surgery
 
for treating Parkinson's.
 
 
 
Mark Stacy,M.D.,a neurologist, co-author of several studies with
 
 
Joseph Jankovic, M.D. presented a talk "Diagnosis of Parkinson's
 
Disease" which was based on "Differential Diagnosis of Parkinson's
 
Disease and the Parkinsonism Plus Syndromes". He also presented
 
another talk, "Novel Treatments in Parkinson's Disease" which was
 
based on a work he co-authored with H. James Brownlee,M.D.
 
"Recognition and Treatment of Early Parkinson's Disease and
 
Other Tremor Disorders".
 
 
 
Dr. Stacy gave me permission to add his reports to our archive,
 
which I will do later.
 
 
 
Dr. Stacy, represented the pharmaceutical viewpoint in treating
 
Parkinson's. Du pont Pharma was a co-sponsor of the symposium.
 
 
 
Dr. Barbara Hastings, a neurologist, gave an excellent presentation
 
on the treatment algorithms for treating Parkinson's as recommended
 
in the American Academy of Neurology Journal(AANJ). More on this will
 
be forthcoming in future posts.
 
 
 
The featured "Star" of the symposium was Dr. Charles Teo, a practicing
 
Pallidotomist from the University of Arkansas Medical Center in Arkansas.
 
He received his skills training under Dr. Iacono and is a contemporary
 
 
of Dr. Gary Heit at the Stanford University Medical Center.
 
 
 
Dr. Teo is a transplanted Aussie who immigrated to the United States.
 
Over the last 10 years he has performed over 60 thalimotomies. He took
 
his pallidotomy training under Dr. Iacano at Loma Linda along with
 
Dr. Gary Heit of the Stanford Medical Center. (See "Neurosurgeon
 
Interview" in the Parkinsn archives.Item# 1716)
 
 
 
Like Dr. Heit, he has performed about 40 Poststero-Ventral Pallidotomies
 
(PVP) using electro-stimulation. Probe placement is verified by
 
ventriculography. Ventriculography, is a process where a small amount
 
of contrast is released into the ventricle of the brain.  A special
 
X-ray is taken using the contrast.
 
 
 
The two most effective surgical options available today are
 
Thalamotomy and Postero-Ventral Pallidotomy.
 
 
 
                Effects of Surgery
 
 
 
            Thalamotomy     PVP
 
 
 
Tremor          +++          ++
 
--More--[Hit space to continue or q to stop.]
Rigidity        +++         +++
 
Akinesia         -          +++
 
Posture          -          +++
 
Dyskinesia      +++         +++
 
 
 
With the exception of Tremor, PVP gives the best results.
 
 
 
              PVP vs Others
 
 
 
PVP exceeds fetal graft
 
Unilateral PVP + Thalamotomy exceeds unilateral PVP
 
PVP exceeds thalamotomy only
 
 
 
The Target Symptoms are:
 
 
 
  * Bradykinesia
 
  * Postural instability
 
  * Gait freezing
 
  * Gait apraxia
 
  * Dystonia
 
  * Torticollis
 
  * Stooped posture
 
 
Dr. Teo stressed patient selection is one of the most important
 
criteria to insure successful outcomes.
 
 
 
Classifications in order of preference are:
 
 
 
  * Juvenile type
 
  * CLASSIC P.D. with partial failure of medication.
 
    (Those patients whose levodopa dosage >800 mg/day)
 
  * Type B P.D. with wide fluctuations in response to med.
 
 
 
Predictors of Good response to PVP are:
 
 
 
  * History
 
    The younger the age the better
 
    Good response to medication
 
    Fluctuating symptoms(on-off)
 
    Off with increase in tremor
 
 
 
  * Examination-Things to look for
 
    Asymmetry, tremor, cogwheeling
 
    Gait freezing, bradykinesia and co-contraction
 
 
    during finger taps.(Controversial)
 
 
 
      CONTRA-INDICATIONS
 
 
 
  * Good control of symptoms with medication
 
  * Tremor without akinesia
 
  * Parkinson-Plus syndromes
 
  * MRI evidence of significant brain stem abnormalities
 
 
 
 
 
 
 
 
 
 
 
Dr. Teo said the bilateral PVP required about 4 hours as compared
 
with 9 hours for those unilateral procedures that also include
 
micro-electrode recording which provide no benefit to the patient.
 
 
 
        STATISTICS
 
 
 
50-90% of patients can expect good/excellent results.
 
5-25% will have no improvement.
 
5-25% will be worse
 
Most patients will require same medication.
 
40-50% will show improvement in cognitive function.
 
 
 
        COMPLICATIONS
 
 
 
   * Visual field defects due to wrong probe placement
 
     (Should be caught by electro-stimulation)
 
   * Speech and swallowing problems
 
   * Hemiparesis
 
   * Intracerebral hemorrhage
 
   * Transient confusion, coma, somnolence
 
   * Death
 
 
 
Dr Teo showed a video of 5 PVP cases that he had performed.
 
 
 
One lady, in her 50s had swallowing, writing and speech difficulties
 
prior to the procedure.  Afterwards, all of her symptoms disappeared.
 
Despite Dr. Teo's counseling not to, the woman stayed symptom free
 
without medication.
 
 
 
Two male subjects in their 60s had postural instability, tremor,
 
and cogwheeling. They were symptom free after the procedure.
 
 
 
One elderly woman had dystonia in one foot and tremor. After the
 
procedure, the dystonia was gone but she couldn't speak.
 
 
 
 
Another woman had tremor in one arm. After the procedure, the tremor
 
was gone but the arm was so weak that she had difficulty raising it.
 
Dr. Teo said that use of a limb generally returns later in the recovery.
 
 
 
    Conclusions:
 
 
 
Dr. Teo was disappointed in his performance to date with an unacceptable
 
number of failures. Intracerebral hemorrhage and speech and swallowing
 
problems were above those reported by Dr. Kelly in his experience.
 
 
 
Since these experiences, Dr. Iacono, has reviewed these cases with
 
Dr. Teo. No conclusions have been reached nor have the mitigating
 
circumstances been found.
 
 
 
It is amazing that Dr.s Teo and Heit both report 40 PVPs performed.
 
I wonder if they counted those in which they assisted with Dr. Iacono?
 
 
 
 
 
 
 
MRI distortion is a fact. Given the close tolerances required in the
 
placement of the probe perhaps the ventriculogram is not as accurate
 
as previously thought and patient confusion during the stimulation
 
phase skewed the results.
 
 
 
 
Preconfiguration of the sterotactic device requires accurate information.
 
 
 
Dr. Teo's results, thus far, appear similar to those reported in
 
the New York Times article at Barrow Neurological Institute which
 
were also disappointing.
 
 
 
The risks appear to outweigh the potential benefit to the Parkinson's
 
patient on these new programs which are trying to replicate, Dr.s
 
Laitenen and Iacono's repopularization of PVP.
 
 
 
Before long the courts will be full with cases from disappointed patients.
 
 
 
John Cottingham                     [log in to unmask]
 
 
 
 
 
Comments:
 
 
 
Dr. Teo did not do a fellowship with Movement Disorders Team, or Dr. IACONO, he
 spent
 
about a week with us.
 
Dr. Teo has slightly different equipment and does things a little bit different.
 
 
 
Dr. Heit did a formal fellowship with Dr. IACONO, and the Movement Disorders Tea
 m
 
at LOMA Linda. Sense returning to Stanford Dr. Heit has performed less than 10
 
 
 
They are both good programs, they however have seen the number of patients we ha
 ve.
 
As there programs grow I think they will develop the feel Parkinson's that we ha
 ve.
 
This a rebirth of an art. The art of Strotaic brain surgery was almost gone a fe
 w years
 
ago. Art & Artists develop at there own speed, and tenchlogy will never replace
 tenche
 
 
 
I will try to answer questions as often as time permits. In general please them
 short.
 
Also please keep them generalized I will answer the questions that are of   gene
 ral interest .
 
 
 
 
 
TONY  SCHOONENBERG
 
MOVEMENT DISORDERS TEAM
 
PEAR REP/ COORDINATOR
 
LOMA LINDA UNIVERSITY MEDICAL CENTER
 
LOMA LINDA CA 92354
 
909-824-4952 office
 
909-824-4825 fax
 
email: [log in to unmask]