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> PALLIDAL STIMULATION FOR PARKINSON'S DISEASE=20
>
>
> PREFACE
>
> This text was written by Geert Ari=EBn, the first (young) Parkinson patient=
> (38 years old), in Belgium who received a pallidal-stimulation. By the=
> operation Geert was delivered from his rigidity, slowness, tremor and=
> involuntary movements. At the same time Geert could reduce his Parkinson=
> medication to the half...A new life can begin !
>
>
> "By this way I want to express my profound gratitude to Prof.Dr. Jacques=
> Caemaert (neurosurgeon ), Dr.Chris Van der Linden (neurologist) and Dirk=
> Caestecker (Medronic-Belgium) for their total dedication and their
valuable=
> advices during my stay in the University Hospital in Gent.
> At the same time I want to thank all the people of the departments=
> Polyclinic Neurology and Admission Neurosurgery for the love and the=
> friendship that I could experience.
>
> My second message of thanks goes to Jean Clement. Jean is Parkie and helps=
> me by the translation of great parts of this article.Thanks, Jean.
>
> To all Parkies who are going to walk the same way, I want to say this : We=
> all know the suffering which we have to experience day by day. Parkinson's=
> disease is a sickness that ties us more or less to this earthly
life...But,=
> as is often the case in many things which are concerned with living and=
> suffering, sunshine comes after rain. Admission to the hospital means a=
> bit of suffering. But I am convinced that this little bit of suffering=
> (rain) is worth while in view of what comes next, namely Sunshine...Merely=
> this tought keeps you upright during your stay in the hospital...Be sure
of=
> one thing: if we all go together hand-in-hand on the way, we will win the=
> fight against Parkinson's Disease in the near future...
>
>
> My war-cry remains meanwhile:
>
> "TO HELL WITH PARKINSON "
>
>
> Tuesday, the 6th of February 1996
>
> Geert Ari=EBn
> Kapelsesteenweg 135
> B-2180 Ekeren
>
> (Tel.:03.644.02.50)
>
>
>
>
>
>
> PALLIDAL STIMULATION FOR PARKINSON'S DISEASE
>
>
> Prof.Dr.J.CAEMAERT (neurosurgeon Univ.Hosp. Gent), Tel.:.09.240.32.56
> Dr.C.VAN DER LINDEN (neurologist Univ.Hosp. Gent),
> Tel.: 09.240.45.29
> Dirk CACAESTECKER (Medronic-Belgium)
> Tel.: 02.460.20.55
>
>
>
> 1. What is Parkinson's Disease ?
>
> Parkinson is a disease which finds its cause in the brain
and is sometimes=
> also called shake-paralysis.
> It is not known how one gets Parkinson. Parkinson is not
hereditary,=
> mortal or infectious.
> There are three major symptoms of the disease : shake
(tremor) stiffness=
> of the muscles (rigidity),slowness of movements (bradykinesia).
> Fatigue is often the result of these manifestations because each movement=
> becomes slower and more difficult. Very often you have to think about the=
> way in which you will perform a movement and sometimes you feel as if you=
> were carrying a block of lead. Besides, due to the tremor, the muscles are=
> permanently active. The shaking gets worse under stress conditions or
when=
> attention is attracted to it.
> Most parkinsonians walk with short steps while bending forward. This may be=
> due to the stiffness of the muscles. Many Parkies have problems with their=
> handwriting that is often wriggly. The greatest problem is that at one=
> moment you can do a lot of things and at the next moment none. People in=
> general do not understand this and find you a poseur.
>
>
> There are still another number of symptoms, although there are as many=
> manifestations as there are patients. Some are very slow, others are hyper=
> mobile. Many patients have a fixed facial expression which gives the=
> impression that they are always angry, infatuated or depressif. There may=
> be complaints about swallowing, constipation, slow piddling, excessive=
> perspiration and excessive saliva.
>
>
> All these symptoms are caused by the loss of certain cells in the brain,=
> with as consequence an insufficient production of the chemical dopamine.=
> The progression of the disease goes along with the decrease of the
dopamine=
> production.
> Dopamine is produced in that part of the brain called the substantia nigra=
> (black substance).=20
>
>
>
>
>
>
>
>
> Dopamine is a link in the chain of neurons: brain-spiral=
> marrow-nerves-muscles.
> The activity of dopamine has an indirect effect on the nerve pathways which=
> go to the spiral marrow and the muscles. If there is only a little=
> activity, then the activity to the spiral marrow will also be disturbed.=
> Neurons and muscles are not in direct contact with each other; they need a=
> (neuro)transmitter substance such as dopamine. In case that there is not=
> enough production of transmitter, other substances, such as acetylcholine,=
> will have the upper hand, causing a disturbance of the balance followed by=
> the appearance of symptoms as in Parkinson's Disease.
>
> Once the loss of cells in the substantia nigra begins, there is no recovery=
> possible. The brain is not becoming "better". However the loss of cells
can=
> be slower by one patient then by another.
>
>
> Treatment with drugs remains symptomatic. Many patients show side effects=
> due to the use of drugs. Others complain that the drugs are ineffective or=
> nearly so.
>
>
> There has been done some work to find solutions to reduce the breakdown in=
> the brain.
> Many years ago operation techniques which brought some relief were already=
> available. As far back as the 1940's stereotactic thalamotomy (tomy means=
> cut trough) was being performed as a treatment for tremor. Stiffness and=
> slow movements were not affected by this operation. Some 25 years ago this=
> operation technique was abandoned in favour of the introduction of the=
> wonderdrug L-DOPA (levodopa). This drug opened indeed new perspectives for=
> many Parkies. Treatment with levodopa relieved all the symptoms of the=
> disease and doctors thought that the disease was cured. Unfortunately,
time=
> has revealed that this is not the case. Patients only get good relief of=
> symptoms for five to ten years. Then the patients become extremely=
> sensitive to the drug so that after they take it the patients get
abnormal,=
> extra movements called dyskinesias. =20
> These dyskinesias can be by themselves disablend. When the activity of the=
> drug wears off, the patients get symptoms of Parkinson's Disease that are=
> worse than if they had taken no medicine at all.
>
>
> 2. History of pallidotomy for Parkinson's disease
>
> Pallidotomy was introduced in 1952 by Dr.Lars Leksell and was successful in=
> relieving many Parkinsonian symptoms in patients. At the same time,many=
> surgeons were performing surgery on the thalamus and for a variety
reasons,=
> thalamotomy became widely accepted, replacing pallidotomy as the surgical=
> treatment of choice for Parkinson's Disease. Thalamotomy,which has an=
> excellent effect on the tremor, was not quite as effective at reducing=
> rigidity. In addition, bradykinesia was often aggravated by the procedure.=
> =20
>
>
> In 1985, Dr.Lauri Laitinen, who had worked with Leksell,
> re-introduced the pallidotomy, as a treatment for patients who had=
> previously undergone thalamotomy but remained symptomatic. Many of his=
> patients suffered from severe bradykinesia, rigidity, tremor and other=
> unusual involuntary movements.These patients had long standing, severe=
> Parkinson's Disease that had been treated with medications for many years=
> and exhibited what is known as drug-induced dyskinesias. He reported his=
> first pallidotomy series of 38 patients in January of 1992 and found that=
> 80-90% of patients had a long lasting relief of symptoms. This encouraging=
> experience prompted other specialists to re-examine the role of=
> pallidotomy.
>
> Science evolves from day to day. Today we have made so much progress that
we=
> can start with pallidal stimulation. Pallidal stimulation is in contrast=
> with pallidotomy a reversible operation. This means that -in the hope that=
> Parkinson's Disease will be cured in the near future- the stimulator and=
> the probe which is on the target in the pallidum can be removed by a
rather=
> simple operation.
>
>
> On simple demand a video of the operation can be obtained by Dr.C.Van der=
> Linden (neurologist at the University Hospital in Gent)
> =20
> 3. What are the effects of pallidal stimulation ?
>
> It is the aim of pallidal stimulation to reduce or keep under control the=
> Parkinson's symptoms, as there are rigidity (stifness), tremor (shake),=
> bradykinesia (slowness) and dyskinesias (involuntary movements caused by=
> Levodopa). At the same time pallidal stimulation makes it possible to=
> reduce in a large measure the anti-Parkinson medication.
>
>
> 4. Who is a candidate ?
>
> -The method is probably most beneficial for the Parkinson patient who had
in=
> the beginning a good response from L-dopa therapy, but who later on=
> developed "ON-OFF" fluctuations
> that were difficult to manage with medication. (if you say "I am ON",this=
> means that you feel allright thanks to the Parkinson medication ; being
OFF=
> means that your medication is no more active. In such a situation you feel=
> muscles becoming rigid, movements becoming slower and tremor developing).
>
> -It is not a reasonable alternative for patients who can keep their
symptoms=
> fairly well under control with the usual anti-Parkinson drugs.
>
> -It is not indicated for patients who suffer from loss of memory, =
> confusion or lack of orientation.
>
>
>
>
>
> -Parkies who want to undergo a pallidal stimulation should stay realistic.=
> At its best the operation cannot cure Parkinson's Disease. Even patients=
> with a serious reduction of their symptoms, still need an anti-Parkinson=
> medication.
>
>
> Now that this new technique is available, we wonder whether we should=
> indeed wait untill the last moment to perform the operation !!!=
> Particularly young patients can become useful and may function quasi=
> normally in society... =20
>
>
>
>
> 5. Operation Procedure=20
> The patient is under sedation, but a general anesthesia is not needed by=
> this method. This makes feedback possible during the operation so that the=
> chance of complications is reduced.
>
> The new technique, which has become available only in the last=
> years,provides in a local stimulation in the pallidum internum from a=
> device similar to a "pacemaker". A thin wire probe is inserted permanently=
> into the pallidum internum in a stereotactic manipulation similar to that=
> for pallidotomy. The (sophisticated) battery (with a life of 3 to 5 years,=
> dependend of the stimulation frequency) is placed under the skin of the=
> patient's chest. The electrical signals can be switched on and off with a=
> small magnet held close to the device. If the Parkinson symptoms fluctuate=
> in the course of the day, then the stimulus can be adjusted. The battery
is=
> replaced through a simple skin incision.
> Probes can be implanted on both sides of the brain, and the side effects
are=
> far fewer than those caused by pallidotomy. The long-term effects are not=
> yet known. (with thalamic stimulation there are 4 years of experience).=20
> The 2 pallidal stimulations performed by Prof.Dr.J.Caemaert (neurosurgeon)=
> and Dr.C.Van der Linden (neurologist) in January 1996 showed the dramatic=
> reductions in tremor, rigidity, bradykinesia and dyskinesias in patients=
> (one of 38 years and one of 61 years) who had been treated by this
surgical=
> method.
> Both patients could reduce their medication to the half. =20
>
>
> 6. Is pallidal stimulation dangerous ?
>
> Stereotactic pallidal stimulation is not without certain risks altough
major=
> morbidity (post-operative harmful consequences) and mortality (death as=
> consequence of surgery )is less than 1% (available statistics about=
> thalamic stimulation).
> One side effect has been a contra-lateral visual field defect. This defect=
> of the visual field, named scotoma, creates a blind spot in the lower=
> visual field. If this occurs on the left side it is generally well=
> tolerated, but on the right side it may disturb reading.=20
>
>
> The incidence of this side effect and other potential side effects are=
> minimized by intraoperative physiologic testing during the procedure.=
> Stereotactic pallidal stimulation is not painful. The surgical target=
> within the pallidum is defined by a CT and/or MRI scan carried out with a=
> special stereotactic frame (Leksell frame )attached to the head. Once the=
> appropriate target coordinates have been selected on a computer station,=
> the patient is taken back to the operating room for the surgical procedure=
> itself. The headhair is shaved and the surgery is carried out under=
> intravenous sedation. A 3 cm skin incision is made in the scalp after=
> infiltration with local anesthesia. Next a hole of about 1 cm is drilled=
> through the skull (a handbore is less frustating than an electrical one).
> A 1.8 mm insulated stimulating electrode is then introduced under impedance=
> monitoring into the postero-ventro-lateral globus pallidus. The target
area=
> is stimulated with very small electrical impulses which may give rise to a=
> variety of different reactions. The purpose of the stimulation is to make=
> sure that the probe lies in the correct area of the pallidum. With=
> electrical stimulation, tremor and rigidity can be reduced almost=
> immediately in the operating room and this confirms accurate placement of=
> the electrode tip. Electrical stimulation may also give rise to visual,=
> motor, sensory or other untoward symptoms and this would indicate that the=
> probe may need repositioning. If symptoms occur even after repositioning,=
> there is a risk that the surgery cannot be performed safely and that the=
> test probe has to be removed without possibility of placing the=
> definitive electrode. When the intraoperative stimulation indicates that=
> the tip of the test electrode lies in the optimal location, then the=
> neurologist (who knows his patient very well) can begin with a detailed=
> intraoperative testing to insure that no neurologic deficit will be=
> incurred when placing the definitive electrode. It also will allow for=
> assessment of beneficial effect on tremor (shake), rigidity (stiffnes),
and=
> bradykinesia (slow movements). If all of this conditions are met, then a=
> permanent electrode is inserted at the chosen location. During the=
> insertion of the final electrode, the patient will be given a variety of=
> motor, visual and psychological tests to check that no adverse effects=
> develop.If unexpected reactions are observed further inserting of the=
> definitive electrode is stopped immediately. It should be noted that=
> neither the test stimulation, nor the implanting of the definitive=
> electrode are painful. Post-operatively the patient is observed in the=
> recovery room for approximately one hour and then returned to his hospital=
> room. He may eat and drink immediately after the surgery and is often able=
> to leave the hospital in a few weeks. The hypokinesia, rigidity and=
> dyskinesia generally improve immediately. Sometimes the tremor does not=
> disappear immediately but gradually diminishes over several days to=
> weeks.If the surgery is successful without side effects, no special=
> post-operative care or training is required. Stitches can be removed one=
> week after surgery. Headache in the post-operative phase is minimal and
can=
> be kept under control.
>
>
> 7. The protocol
>
> The appropriate selection of Parkinson's patients for surgical treatment=
> implies a thorough presurgical evaluation by the operation team=
> (neurosurgeon and neurologist). The protocol includes a detailed history=
> and physical examination as well as videotaping of the patient's=
> preoperative condition. A Uniform Parkinson's Disease Rating Scale is also=
> administered along with a variety of other rating scales. =
> Neuropsychological testing and neuro-imaging is carried out as needed=
> (MRI,PET scanning). This preoperative evaluation is important to ensure
tha=
> the patient is a good candidate for surgical intervention. Many of these=
> scales and tests will be performed post-operatively, to assess the results=
> of surgery in an objective fashion.=20
> =20
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