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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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