Hole in the head gang and others, try this-old but still good:
I'm surprised I was able to find this


Pallidotomy at Stanford University
by Alan Bonander, Leah Schorr, Ph.D., Jon Stedman
Reprinted from Movers & Shakers, newsletter of Young Parkinson's Support=
=0ANetwork of CA, Volume 3 Number 5, 1994


 Stanford University Medical Center in Stanford, CA will be starting a=0A=
pallidotomy program in January / February of 1995.  We thought it would b=
e=0Ainformative to interview one of the neurosurgeons to tell us about th=
e=0Aprogram.  This interview is with neurosurgeon, Gary Heit, PhD, MD, fr=
om=0AStanford University.

Bonander: What is Stanford's interest in the pallidotomy?

Dr. Heit: Dr. Gerald Silverberg, senior neurosurgeon at Stanford, stopped=
 me=0Ain the hallway one day.  He had attended a conference where he hear=
d Dr.=0AMahlon De Long  talk about pallidotomy.  He asked if I would be i=
nterested in=0Asetting up a project for this procedure.  I should give yo=
u just a little of=0Amy background first.  Before I became a neurosurgeon=
 I was a scientist with=0Aspecial interests in cognitive neurophysiology,=
 which deals with how the mind=0Ais expressed by the brain and vice versa=
.  I have done a lot of invasive=0Aintra-cranial recordings in humans in =
working on these various issues.  In the=0Aprocess I had done extensive r=
eading in Parkinson's disease and associated=0Asubcortical dementia.  Dr.=
 Silverberg knew all this, and coupled with his=0Asubtle way of asking, w=
hat was I to do?  He is my mentor.  We had actually=0Atalked about this p=
reviously, but this time we researched all the literature=0Awe could find=
.  We had all of Laitinen's  papers, Leksell's  paper and even=0Ahad foun=
d papers dating back in the 40's on a variant of the pallidotomy.  We=0Ad=
ecided it was a procedure that had merit.  However, the location of the=
=0Alesion is in a very precarious location, between the fibers that contr=
ol=0Amovement and the fibers of the visual tract.  We decided this is not=
 a=0Aprocedure that one can read the book and then do.  We wanted to go s=
omewhere=0Aand learn it.
Bonander: Whom did you contact and where did you go?
Dr. Heit: We looked around and it boiled down to Dr. De Long as our first=
=0Achoice.  However, we were unable to schedule a time with him at that p=
oint.=0AWe contacted Dr. Robert Iacono  of Loma Linda Medical Center and =
he said they=0Awould love to have us.  Dr. Philip Wasserstein, our neurol=
ogist, Dr.=0ASilverberg and myself flew down to Loma Linda and spent two =
days there.  Dr.=0AIacono is a very technically gifted neurosurgeon.  He =
has really advanced this=0Aprocedure to a high art.  The next thing I kne=
w was I was on my way to Loma=0ALinda for two months.  For two weeks I ju=
st watched.  Then I started doing the=0Aprocedure.  I did over 40 pallido=
tomies under the watchful eye of Dr. Iacono.=0AI also did a few thalamoto=
mies.  You might say I've had on the job training.
Stedman: You mean hands-on training!
Dr. Heit: That is better, I have done this procedure over 40 times and I =
have=0Adone it with all the nuances Dr. Iacono has worked out over the la=
st three=0Ayears.
Schorr: Will you be using a CT or MRI scan?
Dr. Heit: Early pallidotomies were performed with CT scan.  The problem w=
ith=0ACT scan is it can give bony landmarks but does not show the fine ar=
chitecture=0Aof the brain.  Today everyone is using the MRI scan.  Since =
both scan=0Atechniques have errors, it is important that electrical stimu=
lation  also be=0Aused to verify probe location.  This safeguards the pat=
ient from the many=0Ainaccuracies of conventional scans.  As a personal c=
omment, I would not have a=0Apallidotomy without electrical stimulation. =
 This is a minimum requirement and=0Ais key to proper lesion  placement.
Bonander: What is the problem with the MRI scanners?  What is the error?
Dr. Heit: Due to construction techniques, the magnet itself introduces a=
=0Adistortion of the image. This distortion is on the order of about 5 to=
 7 mm.=0ANow one can partially compensate for this error by doing a chara=
cterization of=0Athe individual scanner.  This can, at best, cut the erro=
r in half.  Still the=0Aerror is very subtle. There are shifts from patie=
nt to patient of a couple of=0Amm. For some patients the error could be 3=
 mm and on others it could be 9 mm.=0ARelying strictly on MRI scan is ver=
y dangerous.
Stedman: This is a very large error for such delicate surgery.  Can't sof=
tware=0Acorrect this distortion?
Dr. Heit: We are a major GE center for MRI research and we have a man who=
 just=0Afinished his Ph.D. doing just that - removing the distortion in M=
RI imaging.=0AHe is now developing the technique for use in our MRI scans=
.  The other way=0Aaround the MRI distortion is to do ventriculography.  =
This is a very old=0Atechnique but it allows accuracy to within 1 mm or b=
etter.  In=0Aventriculography a small amount of contrast is released into=
 the ventricle of=0Athe brain.  A special X-ray is taken using the contra=
st.  We plan to use this=0Aprocedure until the MRI image correction syste=
m shows itself to be superior.
Schorr: I don't think I have read anything about ventriculography in a=0A=
pallidotomy.
Dr. Heit: Doctors who understand MRI imaging are aware of the 5 to 7 mm e=
rror.=0AThere was a patient whom Dr. Iacono and I reviewed who had had a =
pallidotomy=0Awithout electrical stimulation, with reliance totally on th=
e MRI scan for=0Atargeting the location of the lesion.  The lesion was in=
 the internal capsule=0Aand the patient became hemiplegic  and will stay =
that way.  There was nothing=0Awe could do.  Relying solely on MRI guidan=
ce is very dangerous.
Dr. Heit: The way the procedure works is: an MRI is taken and then=0Avent=
riculography is performed.  We then introduce the probe and do electric=
=0Astimulation.  This gives us an idea how close we are with the probe to=
 the=0Aoptic tract and to the internal capsule.  From Dr. Iacono I have l=
earned where=0AI must be with the probe for specific heat levels and dura=
tion of probe=0Aheating.  Periodically the probe location is verified usi=
ng ventriculography.=0AThis is how Dr. Iacono does the pallidotomy.  We w=
ill be spending time with=0ADr. De Long's group at Emory in Atlanta.  We =
may choose to modify our=0Aprocedure based on their information.  Our pla=
n is to combine the best=0Afeatures from both centers to form our procedu=
re.
Schorr: Will you be doing micro recording also?
Dr. Heit: I did a lot of micro recordings when at Loma Linda. We often fo=
und a=0Alot of hyperactivity in the pallidum; however, sometimes there wa=
s no activity=0A- a quiet pallidum. Those patients did well and I do not =
know how to explain=0Athat. We will have our own micro recording program =
to help us better=0Acharacterize the pallidum. This all leads to the basi=
c problem of patient=0Aselection.
Dr. Heit: There is not a set of definitive qualifications for selecting t=
he=0Abest candidates for the pallidotomy.  Occasionally, when working wit=
h Dr.=0AIacono, we would find patients we felt to be ideal for the proced=
ure; however,=0Aafter the procedure the improvement may have been margina=
l for some of these=0Apatients.  Conversely, where we did the procedure o=
n a compassionate basis,=0Awith little expectation for good, the procedur=
e yielded spectacular=0Aimprovement for some patients.
Bonander: How does Stanford plan to advance the patient selection process=
?
Dr. Heit: Here at Stanford we have a pool of incredibly talented people. =
 We=0Ahave recruited a group of neuropsychologists who have developed bot=
h research=0Aand clinical tests to be administered both before and after =
the surgery.  This=0Awill be used to evaluate change in cognitive functio=
n as well as motor=0Aperformance.  Neuroradiology is doing a number of th=
ings to improve our=0Atargeting procedure as well as to develop a precise=
 MRI scan.  They also have=0Asome interesting ideas on using new MRI tech=
nology.  We hope their work will=0Ahelp us better delineate good candidat=
es for the pallidotomy.
Bonander: What value is this surgery to those diagnosed as Parkinson's Pl=
us?
Dr. Heit: All indications are that the surgery is of limited value to thi=
s=0Aclass of patient.  Initially we will not be looking at this group.  W=
e expect=0Ato see patients who have been misdiagnosed and are searching f=
or answers.=0ASome of this group may well have one of the Parkinson's Plu=
s diseases.
Stedman: Will anything be done post-op for the patients?
Dr. Heit: One area of special interest is rehabilitation.  The rehabilita=
tion=0Astaff is ecstatic about the possibilities.  There is a population =
of patients=0Awith very debilitating Parkinson's disease and, to date, li=
ttle could be done=0Afor them.  If neurosurgery can reverse much of the d=
yskinesia, akinesia,=0Abradykinesia and tremor after, maybe, ten years of=
 debilitating disease, we=0Acannot then send them out after surgery and s=
ay, "That's it."  There may be a=0Aneed for physical, occupational and/or=
 cognitive rehabilitation.  One thing we=0Aare doing is designing a compr=
ehensive rehab program.  We have the capability=0Ato help the patient as =
necessary to re-enter society.  In the long run we want=0Ato become a tru=
e movement disorder center.
Schorr: This sounds very extensive.  What are the patient requirements?
Dr. Heit: We will be asking patients to come for a week of pre-op clinica=
l and=0Aresearch assessments.  A patient will be evaluated by various gro=
ups to assure=0Aproper medication and to determine severity of disease.  =
All staff members=0Awill review the pre-op patient information.  The deci=
sion to proceed with=0Asurgery will be made during a group meeting.  Afte=
r surgery we ask that the=0Apatient stay in the area for a few days.  We =
want to be near the patient=0Ashould questions arise or problems develop.=
  If the patient needs rehab, they=0Awill be asked to stay in the area.  =
We will be doing 3, 6 and 12 month follow-=0Aup evaluations and maybe fol=
low-ups annually for many years.
Bonander: As much as patients like to think they are making rational deci=
sions=0Aabout surgery, I believe the decision is emotional. All the ratio=
nal thinking=0Ahappened before contact with the neurosurgeon. PD patients=
 normally have not=0Aexperienced neurosurgery. I had had an appendectomy =
some fifteen years=0Aearlier. That was my surgical experience. I was very=
 naive when I had my=0Apallidotomy in Sweden. I had expectations that wer=
e realistic when I talked=0Aabout the surgery to others; however, deep do=
wn inside me I wanted to leave=0Aall my Parkinson's disease in the OR. Th=
at may have been an unreal=0Aexpectation, but it was my unspoken hope.
Dr. Heit: Setting realistic expectations for the surgery is very importan=
t.=0AIn the initial evaluation before surgery expectations will be discus=
sed.=0AThere are risks that need to be understood.  There must be hope fo=
r=0Aimprovement, no matter what the risks are.  Unfortunately, the pallid=
otomy is=0Anot a cure.
Schorr: All this is great, but it could be very expensive.
Dr. Heit: Some of the work is clinical and the patient's insurance will b=
e=0Abilled.  The remaining research will not be billed to the patient.  W=
e will=0Awork with the patient and with their insurance company.  Palo Al=
to is an=0Aexpensive area, so we have talked to our social services group=
 about the=0Aavailability of low cost accommodations.  This is their area=
 of expertise.  I=0Aknow Dr. Iacono has patients coming from all over the=
 world, as does Stanford=0AMedical Center.  Concerns for the logistics ar=
e very important to both the=0Apatient and the caregiver.
Bonander: How do you view the pallidotomy as a neurosurgical procedure?
Dr. Heit: In the scale of neurosurgical interventions it is not a very=0A=
technically challenging surgery, but it is intellectually very challengin=
g. It=0Ais this side that has my interest. It has a lot of inferential an=
alysis that=0Arequires knowing what you are doing. Additionally my backgr=
ound as a scientist=0Amakes this procedure interesting to me.
Bonander: How does a patient use the services of Stanford University Medi=
cal=0ACenter?
Dr. Heit: They may call either Dr. Philip Wasserstein's office at (415)=
=0A723-6469 or call my office at (415) 723-5572 and tell us they are a=0A=
Parkinson's patient interested in our program.  If you call my office and=
 I am=0Anot in you will most likely speak to Melinda Fike, RN, (415) 725-=
5280.=0AMelinda is the nurse practitioner for Parkinson's disease in the =
Department of=0ANeurosurgery.  She should be able to explain the program.=
  You may also call=0Athe Stanford Referral Center at (800) 756-5000.  Re=
cently I had a call from a=0Alady who said she had just been diagnosed wi=
th PD and wanted the operation=0Athat best fit her disease.  Obviously sh=
e needed education in the treatment of=0APD.  We will be asking some ques=
tions on the telephone.
Bonander: What about stimulation therapy?
Dr. Heit: Stimulation is another area of particular interest to me.  Rath=
er=0Athan placing a lesion, as we do in the pallidotomy, an electrical wi=
re is=0Aplaced in the appropriate location in the brain.  The wire is con=
nected to a=0Aprogrammable device that will provide an electric stimulus =
either on demand or=0Aon a programmed interval.  This is similar to the h=
eart pacemaker in concept.=0AStimulators have been placed in the thalamus=
, pallidus and subthalamic=0Aregions.  The risks of subthalamic stimulati=
on are too high, but the other=0Aareas are very interesting.  While placi=
ng a surgical lesion is irreversible,=0Ainserting a wire for stimulation =
is reversible.  It is a new and exciting area=0Athat I expect also to res=
earch.  In the not-too-distant future this may also=0Abe available to pat=
ients at Stanford.
Bonander: The San Francisco Bay Area is loaded with molecular technology=
=0Afirms.  I know Stanford is involved with many of them.  Do you see any=
thing in=0Athe near future from this involvement?
Dr. Heit: I am researching a technique that will allow removing a small s=
ample=0Aof tissue just before the lesion is made.  This will be handed of=
f to the=0Avarious sciences for further study.
Dr. Heit: While at Loma Linda I was stunned at the technical expertise of=
 the=0AParkinson's patient.  I met team member, Tony Schoonenberg , a par=
kinsonian.=0ATony researched papers written in the 60's and 70's and it w=
as astonishing=0Awhat he was finding.  The more I learn about Parkinson's=
 disease the more I=0Aseem to find it a disease with a wealth of ignored =
information.  The=0Apharmacological expertise of Tony and other patients =
stunned me.  You have the=0Aadvantage of empiricism, you are living this =
problem.  I also learned there=0Awere patients selected by their support =
group to be the first member to try=0Athis procedure.  If the results of =
the surgery were good, others would follow.=0AThe aggressive character of=
 support groups was a pleasant surprise.
Schorr: People with Parkinson's disease in support groups tend to care ab=
out=0Aeach other.  There is a real sense of community in support groups. =
 When a=0Amember tries a new therapy, we all want that therapy to benefit=
 the member and=0Awe hope it will help each of us.  We know PD is differe=
nt in each of us.  I=0Aknow Alan, Jon and I react differently to the same=
 medication.  Both Jon and=0AAlan find Eldepryl benefits them.  For me, E=
ldepryl makes me hallucinate.  I=0Awas calling 911 repeatedly in the midd=
le of the night while on an initial=0Atrial of Eldepryl.  I had to discon=
tinue its use.  PD is a complex disease.=0ASupport groups take some of th=
e complexity away.  We find we are not alone.
Dr. Heit: I think PD is a cluster of diseases with known similarities.  T=
he=0Adifferences are the unknowns.  Why does one patient have dyskinesia =
while=0Aanother is bothered by dystonia?  Support groups are indeed an im=
portant part=0Aof living with this disease and understanding these differ=
ences.
Dr. Heit: While we are talking about support groups, we want to talk to=
=0Asupport groups about our program at Stanford, but more than that, we w=
ant to=0Alearn from the experts - those living with PD.  You have a lot t=
o teach us.=0AAll the members of the Stanford team are interested in visi=
ting support=0Agroups.
Bonander: I just have one request from the patient community.  Please rem=
ember=0Awe are awake during the operation.  Comments about not being able=
 to find the=0Abrain or that there seems to be no activity in the brain w=
ill be heard by the=0Apatient.
Dr. Heit: I do many procedures where the patient is awake.  This is not n=
ew to=0Aneurosurgery.  Usually the biggest discussion in the OR is which =
CD to play.=0AThis is now the choice of the patient.
Bonander: Almost three hours have disappeared.  I want to thank you for t=
aking=0Athis time from your busy schedule to explain Stanford's pallidoto=
my program.=0AWe have learned much and I am sure the readers of this inte=
rview will learn=0Amuch.  We will be better decision-makers.  I would lik=
e to propose a deal that=0Asounds good to me.  I will cover the dinner to=
night if you will cover a=0Apallidotomy for each of us, should we choose.
Dr. Heit: I think I have just been had!!

NOTE: This was a most informative interview.  Leah, Jon and I learned muc=
h=0Aabout neurosurgery, MRI scans, psychological testing, and much more t=
hat time=0Aand space limitations have forced us to omit.  We would like t=
o thank Dr. Gary=0AHeit for giving us this interview.  Support groups wis=
hing to have Dr. Heit or=0Asomeone else from the Stanford program speak t=
o them should contact Melinda=0AFike at (415) 725-5280 or by fax at (415)=
 723-7813 for details.
=A2.



Pallidotomy Centers
Editor's Notes: The following neurosurgeons have performed the pallidotom=
y=0Aand/or thalamotomy procedure(s).  This list is not complete.  I have =
tried to=0Agive the correct telephone numbers for inquiry.  If these are =
incorrect, call=0Ainformation in the listed city for the Institution.  Th=
is is NOT a list of=0AYPSN approved neurosurgeons.  There is no such list=
.

CALIFORNIA
City=09Institution and / or Facility=09Neurosurgeon=09Telephone=09Fax
Irvine=09University of CA, Irvine (UCI)=09Michael Dogali=09(714) 456-6966
La Jolla=09Scripts Clinic=09Howard Tung=09(619) 554-8163
Loma Linda=09Loma Linda Medical Center=09Robert Iacono=09(909) 796-4822
Los Angeles=09Hospital of the Good Samaritan=09Skip Jacques=09(800) 762-1=
692
=09=09Oleg Kopyoff=09(800) 762-1692
=09University of CA, Los Angeles (UCLA)=09Antonio De Salles=09(310) 794-1=
221
=09University of Southern CA (USC)=09William Caldwell=09(213) 342-5791
Palo Alto=09Stanford University Medical Center=09Gary Heit=09(415) 723-66=
61=09(415)=0A723-7813
=09=09Gerald Silverberg=09(415) 723-6661=09(415) 723-7813
San Francisco=09University of CA, San Francisco (UCSF)=09Nicholas Barbaro=
=09(415)=0A476-4768
Santa Monica=09John Wayne Cancer Institute=09Robert Rand =09(310) 315-612=
5
Sunnyvale=09The Parkinson's Institute=09Laszlo Tamas=09(408) 734-2800

OUTSIDE OF CALIFORNIA
City=09Institution and / or Facility=09Neurosurgeon=09Telephone=09Fax
Atlanta, GA=09Emory University=09Roy Bakay=09(404) 727-4508=09(404) 727-3=
157
=09=09Jerrold Vitek=09(404) 727-4508=09(404) 727-3157
Boston, MA=09Massachusetts General Hospital=09Rees Cosgrove=09(617) 724-0=
357
=09University of Boston=09Arthur Rosiello=09(617) 638-8992
Chicago, IL=09Rush Medical Center=09Richard Penn=09(312) 942-6644
Lebanon, NH=09Dartmouth Hitchcock Medical Cntr.=09David Roberts=09(603) 6=
50-8736
Minneapolis, MN=09University of Minnesota=09Robert Maxwell=09(612) 624-11=
14
New Brunswick, NJ=09Rutgers University=09Richard Lehman=09(908) 235-7756=
=09(908)=0A235-7095
New York City, NY=09New York University Medical Center=09Patrick Kelly=09=
(212)=0A263-8002=09(212) 263-8031
St. Louis, Mo=09St. Louis University=09?? Jamie Henderson ??
Portland, OR=09Oregon Health Sciences University=09Kim Burchiel=09(503) 4=
94-5285
Phoenix, AZ=09Barrow Neurological Institute=09Andrew Shetter=09(602) 406-=
6315=09(602)=0A406-7178
Salt Lake City, UT=09University of Utah=09Peter Heilbrun=09(801) 581-6908

INTERNATIONAL
City=09Institution and / or Facility=09Neurosurgeon=09Telephone=09Fax
Canada, Toronto=09The Toronto Hospital=09L.  Lozano=09(416) 369-5875
 (For information on Canadian pallidotomy facilities call Ms. Jan Duff, R=
N,=0AClinic Coordinator at (416) 369-5875.)
England, London=09(The neurosurgeon taking over the practice of the late =
Dr.=0AHitchcock)
Japan=09=09H.  Narabayashi
=09=09Chilori Ohye
Sweden, Stockholm=09 Sophiahemmet Hospital=09Lauri V.  Laitinen=0946 8 66=
0-1489=0946 8=0A660-1421
=09=09Marwan Hariz=0946 8 660-1489=0946 8 660-1421
Switzerland, Zurich=09=09Jean Siegfried