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Deep Brain Stimulation: Adi Sulistyanto MD Staff Neurosurgeon National Brain Center Jakarta, Indonesia

Deep brain stimulation (DBS) involves surgically implanting electrodes into targeted areas of the brain and connecting them to a medical device similar to a pacemaker to deliver electrical stimulation for treatment of neurological disorders. DBS targets include areas of the brain like the subthalamic nucleus and has been shown to be effective for treating motor symptoms in Parkinson's disease, essential tremor, and dystonia. The DBS procedure involves brain imaging, frame placement, targeting, macrostimulation testing, and implantation of electrodes connected to a battery pack. Studies show DBS can significantly improve motor function in Parkinson's based on UPDRS scores with low complication rates. However, DBS is an expensive procedure requiring insurance coverage.

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Yobbi Arissaputra
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90 views

Deep Brain Stimulation: Adi Sulistyanto MD Staff Neurosurgeon National Brain Center Jakarta, Indonesia

Deep brain stimulation (DBS) involves surgically implanting electrodes into targeted areas of the brain and connecting them to a medical device similar to a pacemaker to deliver electrical stimulation for treatment of neurological disorders. DBS targets include areas of the brain like the subthalamic nucleus and has been shown to be effective for treating motor symptoms in Parkinson's disease, essential tremor, and dystonia. The DBS procedure involves brain imaging, frame placement, targeting, macrostimulation testing, and implantation of electrodes connected to a battery pack. Studies show DBS can significantly improve motor function in Parkinson's based on UPDRS scores with low complication rates. However, DBS is an expensive procedure requiring insurance coverage.

Uploaded by

Yobbi Arissaputra
Copyright
© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
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DEEP BRAIN STIMULATION

Adi Sulistyanto MD
Staff Neurosurgeon
National Brain Center
Jakarta, Indonesia
dr Adi Sulistyanto, SpBS

Cirebon, 4 Agustus 1981


FK UI 1999-2005
Sp SpBS FKUI 2009-2015
Fellowship: Stereotactic Functional
Neurosurgery
University British Columbia, Canada 2016-2017

Afiliasi RS Pusat Orak Nasional


DISCLOSURE
 None
WHAT IS IT?

Brain Pacemaker for


neurological disorder
1920’s-60’s  stereotactic procedures and ablative surgery predominantly
used to treat movement disorders symptoms

Levodopa in mid 1960’s

Levodopa and a number of dopamine agonists  effective relief of


motor symptoms in early stage, but occurrence of motor complications

1987  French neurosurgeon Alim Benabid introduced the “chronic”


HISTORY high-frequency DBS approach for Parkinson’s Disease

Martinez-Ramirez D, Hu W, Bona AR, Okun MS, Shukla AW. Update on deep brain stimulation in parkinson’s disease. Translatoional
Neurodegeneration. 2015;4:12:
Indications

1. Idiopathic Parkinson Disease


2. Essential Tremor
3. Primary Generalized Dystonia

4. Obsessive Compulsive Disorder

- Neuropathic Pain
- Epilepsy
- Disorder Of Consciousness
- Alzheimer
- Obesity
- etc
TARGETS
PATIENT SELECTION CRITERIA
Sensitivity to L-Dopa is the most significant outcome predictors

Inclusion criteria Exclusion (relative)

• Clinically idiopathic PD • Biological age >75 y.o


• Significant improvement with • Severe/malignant comorbidity
regard to dopaminergic with considerably reduced life-
medication (>30%) expectancy
• Refractory motor fluctuations or • Chronic immunosupression
tremor • Distinct brain atrophy
• Only minor symptoms during ON- • Severe psychiatric disorder
state

Larson PS. Deep brain stimulation for movement disorders. Neurotherapeutics. 2014 Jul; 11(3):465-74
Moldovan A, Groiss SJ, Elben S, Sudmeyer M, Schnitzler A, Wojtecki L. The treatment of parkinson’s disease with depp brain stimulation: current
issues/ Neural Regen Res. 2015 Jul;10(7):1018-22
Groiss SJ, Wojtecki L, Sudmeyer M, Schnitzler A. Deep brain stimulation in Parkinson’s disease. Ther Adv Neurol Disord. 2009;2(6):379-91
Image courtesy of singhealth
http://www.yoonsupchoi.com/wp-content/uploads/2015/09/UPDRS-620x350.png
DBS SURGERY

 Frame
DBS SURGERY

 Localizer
DBS SURGERY

 MRI / CT Scan
 MRI

DBS SURGERY
-
-6 mm -
-5 -
-4
-3
- STN
-2 - STN
-1 - STN
0 (target)
+1
- STN
+2 - STN
+3 -
-
-
-6 mm -
-5 -
-4
-3
- STN
-2 - STN
-1 - STN
0 (target)
+1
- STN
+2 - STN
+3 -
-
MACROSTIMULATION
Image courtesy of medtronic
PROGRAMMING
OUTCOME

Complication rate (permanent) n>400


 No deaths <30d
 0.5% stroke
 3% infection
 4% (temporary) stimulation effect
N = 124
 ↑UPDRS >50%
 ↓dyskinesia 80-100%

 Stroke 0%
 Death 0%

SUBTHALAMIC NUCLEUS DBS


DBS FOR PD

Conclusion

In this 6 month study of patients under 75 years of age with severe motor
complication deep brain stimulation of subthalamic nucleus is superior to best
medical treatment
DBS FOR PD

Conclusion
Marked improvement over five years in motor function. Still
worsening of postural stability, speech, cognition which is
consistent with natural history
COST
 EXPENSIVE!!

 Initial implant + battery change

 GOLD STANDARD

 Insurance? JKN? Private?

 Neurologist and Neurosurgeon should generate demand and


advocate for patients
ALTERNATIVES

 Pallidotomy / Thalamotomy

 Duodopa

 Apomorphine
THANK YOU

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