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