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 stategies 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 +++ ++
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]
