Deep Brain Stimulation

Overview of Deep Brain Stimulation in India

Deep brain stimulation is a procedure that places electrodes in different brain areas for stimulation. At times, the brain creates the abnormal nerve impulses, which then creates the abnormal response in the body. The electrodes are then placed to control these abnormal impulses, thereby stopping the body's abnormal reaction.  The electrodes are attached to a device that is like a pacemaker. Its function is to control the amount of stimulation in the deep brain stimulation treatment. The pacemaker is placed under the skin in the area of the chest. 

The wire from the pacemaker runs under the skin and toward the brain where it connects to the electrodes for deep brain stimulation. Deep brain stimulation is used for degenerative disorders of the brain, movement disorders and the conditions in which abnormal impulses are being generated in the brain like epilepsy. Deep brain stimulation treatment is used after all of the aggressive medication to treat the condition are no longer effective and there is no other way of treatment.

While deep brain stimulation is considered a low risk procedure, it does have several risks and complications which must be managed otherwise can potentially lead into life threatening conditions such as a stroke. Deep brain stimulation is never performed unless the advantages of the surgical treatment significantly outweigh the associated risks and complications.

Types of Deep Brain Stimulation:

Stereotactic Deep Brain Stimulation

In general surgery is done with the patient off their medication. An head frame is placed on the patient's head to stabilize it and provide coordinates for the surgeon to follow for placing the lead in the targeted area of the brain. Local anesthesia is injected into the scalp to maximize comfort for the patient while also providing the patient with a sedative to relax the patient throughout the surgery.

Image-guided Deep Brain Stimulation

In an image-guided Deep Brain Stimulation surgery, -i.e., interventional MRI or CT scan, the patient is typically asleep under general anesthesia. The surgeon uses images from the patient's brain to focus on placing the Deep Brain Stimulation precisely and to the desired target.

Awake Deep Brain Stimulation

Awake deep brain stimulation surgery is typically used, in which an awake patient must stop temporarily taking the medications that manage their disease. The patient helps direct the placement of the Deep Brain Stimulation electrode in precise location of the brain by performing tasks. While it is typical to be awake during surgery, and it is usual to be off medications, this can be uncomfortable to some persons.

Asleep Deep Brain Stimulation

There is the other option of deep-brain stimulation and this may be completed at clinical locations too. Asleep Deep Brain Stimulation surgery is completed when the patient is sleeping and under general anesthesia. The surgery can be completed inside of an MRI or CT scanner, allowing for accurate targeting and verification of the placement of the Deep Brain Stimulation electrodes.

Procedure:

Preoperative Assessment

The patient is to inform the physician of any past and current medications (including dosage/frequency of any medication). The patient is also to disclose what vitamins or supplements they take at the current time.

Diet

The patient is to refrain from eating or drinking anything after midnight, the night before the surgery.

Medications

The patient is to stop taking Aspirin, Ibuprofen, Advil, etc., one week before the surgery date. It is also required that any medications that the patient takes currently, to treat their present neurological condition, for example: Parkinson's or dystonia, also not be consumed after midnight, the day of surgery.

The patient needs to be admitted to the hospital one day before the surgery.

Procedure of Deep Brain Stimulation

Here is an overview of the general procedure of Deep Brain Stimulation: 

Preoperative Evaluation: Before the surgery, a thorough evaluation to determine appropriateness for Deep Brain Stimulation will include the medical history, a physical examination, and potentially, various imaging or diagnostic testing such as MRI or CT scans to identify the appropriate target location within the brain.

Target Selection: A specific target location for stimulation will be selected based on the diagnosed condition, symptoms, and response to medications. The target location and area relates to the particular circumstances of individual cases and regions of the brain or brain disorder being treated.

Surgical Planning: Imaging will be used with  CT or MRI scans to plan the route and angles of approach and placements for the electrodes to minimize the potential for damage to adjacent brain structures. 

Anesthesia: The anesthesia plan will be based on the option employed, whether awake or asleep Deep Brain stimulation. In awake cases, local anesthesia and mild sedation could be used.

Implantation of the electrodes:  For newer systems, this is most often done using an awake craniotomy technique, based off the patient's input to determine electrode placement. To complete stimulation, a neurosurgeon will drill a small hole in the skull and will take recording of the selected area of the brain.

Implantation of the accelerator:  The accelerator can be compared to a pacemaker that produces electrical impulses to the brain. After placing electrodes in the brain, accelerators are then used to develop impulses. An incision is made where the accelerator will be put into the upper chest area.

Programming and testing:  Once the surgery has taken place, it will take some time to recover and a few programming sessions will be completed to get stimulation optimized. A neurologist will adjust stimulation parameters to get the most effective and comfort results which will improve the patient's symptoms with the least amount of side effects.

Follow-up care:  Follow-up visits will be at regular intervals to follow progress and, if needed, adjustments to ensure success with the Deep Brain Stimulation acute and chronic treatment modalities.

Follow-Up After Deep Brain Stimulation (DBS) Surgery

The patient is usually discharged within one or two days of DBS surgery. Before discharge, the patient is provided with a complete set of instructions for home post-operative care. After approximately 10 days the patient returns to the hospital for a follow-up, where the staple/suture removal occurs. An initial programming appointment is also made for 2-3 weeks after surgery, at which time the electrical stimulation is turned on. The patient is provided a list of instructions for their use, intended to accelerate recovery as well as minimize the risks for complications.