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Parkinson's Pacemaker

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LOS ANGELES, Calif. ( Ivanhoe Newswire) - One million Americans are living with Parkinson's. Once the disease progresses, even medication can't stop its most noticeable and debilitating symptom. Now there's a brain implant offering relief.

Shaking is the tell-tale sign of Parkinson's. For Ernest and his wife, the shaking was the first piece of a puzzle that led to his Parkinson's diagnosis. He got the news right after his wife was diagnosed with lung cancer.

"It just started with a tremor, and the tremor started getting worse when I started going through chemo," Dorinda Garcia, Ernest's wife, told Ivanhoe.

UCLA neurosugeon Antonio De Salles said a lack of neurotransmitters causes the tremors.

"The cells are dying in a part of the brain," Antonio De Salles, M.D., Ph.D., a neurological surgeon at UCLA Medical Center, said.

Medication helps, but over the years, the cells continue dying and the brain starts to be over sensitive to the medication, so too much of the medication will cause tremors. Too little causes paralysis. Ernest opted for deep brain stimulation surgery

"He started to depend on his wife for changing clothes, feeding him, taking care of him on everyday things," Dr. De Salles, said.

Using cat scans and MRI, doctors guide electrodes into the brain. During surgery, Ernest was actually awake, helping guide surgeons to the right spot.

"I had to move my hands, move my feet," Ernest said. "I started singing ‘Wise Men Say Only Fools Fall in Love'."

The electrodes become a pacemaker for the brain and electrical impulses correct abnormal cell function.

"It's high frequency electricity coming to a specific area of the brain that's out of control," Dr. De Salles said.

The pacemaker is then permanently placed into the patient's chest. It worked for Ernest.

"He definitely moves better and speaks better," Dr. De Salles said.

"I remember thinking hallelujah," Ernest said.

"It really has helped," Dorinda said.

Now he's regained control of his movements, his speech and his life. The batteries in the pacemaker need to be replaced every four to six years. There is a risk during the operation of bleeding in the brain, which could cause stroke-like symptoms, but Doctor De Salles said it's extremely rare. He said of the 500 surgeries he's performed it's happened in less than half of one percent of his patients.

RESEARCH SUMMARY

BACKGROUND: Parkinson's disease is a progressive disorder of the nervous system that affects movement. It develops gradually, often starting with a barely noticeable tremor in just one hand. While tremor may be the most well-known sign of Parkinson's disease, the disorder also commonly causes a slowing or freezing of movement. There's no cure for Parkinson's disease, but medications can help control some of the symptoms of Parkinson's disease, and in some case, surgery may be helpful. (SOURCE: Mayo Clinic)

CAUSES:
A small region deep within the brain is the source for the symptoms of Parkinson's disease. When brain neurons in this part of the brain begin to die, these cells can no longer manufacture the molecule dopamine -- a chemical critical for controlling movement. The exact cause of Parkinson's disease is unknown, but several factors appear to play a role, including genes. Researchers have found specific genetic mutations that likely play a role in Parkinson's disease. In addition, scientists suspect that many more changes in genes -- whether inherited or caused by an environmental exposure -- may be responsible for Parkinson's disease. Exposure to toxins or certain viruses may trigger Parkinson's signs and symptoms. (SOURCE: Mayo Clinic)

CHANGING THE GAME: Deep brain stimulation (DBS) is a surgical procedure used to treat a variety of disabling neurological symptoms—most commonly the debilitating symptoms of Parkinson's disease (PD), such as tremor, rigidity, stiffness, slowed movement, and walking problems. The procedure is also used to treat essential tremor, a common neurological movement disorder. At present, the procedure is used only for patients whose symptoms cannot be adequately controlled with medications. DBS uses a surgically implanted, battery-operated medical device called a neurostimulator—similar to a heart pacemaker and approximately the size of a stopwatch—to deliver electrical stimulation to targeted areas in the brain that control movement, blocking the abnormal nerve signals that cause tremor and PD symptoms. Before the procedure, a neurosurgeon uses magnetic resonance imaging (MRI) or computed tomography (CT) scanning to identify and locate the exact target within the brain where electrical nerve signals generate the PD symptoms. Some surgeons may use microelectrode recording—which involves a small wire that monitors the activity of nerve cells in the target area—to more specifically identify the precise brain target that will be stimulated. Generally, these targets are the thalamus, subthalamic nucleus, and globus pallidus.

The DBS system consists of three components: the lead, the extension, and the neurostimulator. The lead (also called an electrode)—a thin, insulated wire—is inserted through a small opening in the skull and implanted in the brain. The tip of the electrode is positioned within the targeted brain area. The extension is an insulated wire that is passed under the skin of the head, neck, and shoulder, connectng the lead to the neurostimulator. The neurostimulator (the "battery pack") is the third component and is usually implanted under the skin near the collarbone. In some cases it may be implanted lower in the chest or under the skin over the abdomen. Once the system is in place, electrical impulses are sent from the neurostimulator up along the extension wire and the lead and into the brain. These impulses interfere with and block the electrical signals that cause PD symptoms. (Source: National Institute of Neurological Disorders and Stroke)

INTERVIEW

Antonio De Salles, MD PhD, Neurological Surgeon at UCLA Medical Center, talks about how a pace-maker for the brain is helping people with a devastating disease.

What causes the shakes and the tremors in Parkinson's?

Dr. DeSalles: The shakes and the tremors appear to be due to the fact that the patieint is not having proper control of the muscles through the brain. The brain is not doing the proper job. A particular area of the brain is not functioning properly; therefore, the patient has this motor tremors and slowness. Basically, the computer that takes care of our motor function is not working right.

Can the medication cause some of the tremors?

Dr. DeSalles: No. the medication actually protects the patients that initially appear with tremor because it is just a replacement of a neurotransmitter. It's replacing a neurotransmitter that the brain is not producing and should produced. Dopamine is the neurotransmitter. The patient is no longer producing that dopamine because the cells responsible for this function are dying in a specific area of the brain called the substantia nigra. Over the years, the cells continue dying and the brain starts to be oversensitive to the medication. Too much of the medication will then cause tremors/abnormal movements.

Are those tremors what confines a person with Parkinson's to their house and their bodies?

Dr. DeSalles: The tremor is an important part of the symptoms of Parkinson's disease, but there are others that are very unpleasant such as very slow movement. They have difficulty to walk and many times they lose their balance. They also have difficulty swallowing and many times difficulty speaking. That evolves over time during their disease. When they look for a surgeon like me, they are in that point where getting out of the house is difficult, taking care of themselves is difficult, and the medication when taken starts to give too much abnormal movements, too much tremors, because they are too sensitive to the medication.

When you met Ernest, what was he like?

Dr. DeSalles: He was quite slow. He had difficulty moving. He had a little bit of tremor. His voice was very low. He was starting to depend on his wife for changing clothes, taking care of simple tasks, putting food in his mouth, taking care of him on everyday things. They decided that they would go for surgery.

Is surgery a last effort for sufferers?

Dr. DeSalles: Used to be so. Used to be that the patients would go all the way to being almost unable to take care for themselves like he did. However, now we know that surgery is quite effective. We like to do surgery in very young Parkinson's disease patients that are still working, but they are almost not being able to work. They still take care of themselves. They are part of the family. They are socially quite well; however, they are starting to lose their job. They are starting to be incapable to do their functions at work. We like to operate on those patients because we will bring them really to society for the next 15 or 20 years in their lives.

If you don't catch it at that point, do you see them go down faster?

Dr. DeSalles: The speed to which they go down is independent of doing the operation or the medication or not. Every individual is different. Some of them have a very fast progressing Parkinson's disease. Others will have it slow. However, we would like to pick them up before they are unable to work. They feel useful. They contribute to society and they will do well for a long period of time. Otherwise, they will lose their jobs and now they are retired or they are disabled, and that is a label that they will carry in front of their families and in front of society, which is a very difficult one to carry.

How does DBS works?

Dr. DeSalles: The Parkinson's disease enters in a situation where the neurotransmitter dopamine is not available. Therefore, some cells in an area of the brain or two or three areas of the brain that are related to motor function start to be hyperactive because they are not modulated by the dopamine. Dopamine is a neuromodulator, a neurotransmitter that is making those cells work appropriately; activate, deactivate depending on what the person wants to do. When that is not happening because of lack of dopamine, those cells are very active. They are firing in an uncontrolled fashion. The patient will have tremors or the cells fire so much that the muscles become very rigid leading to muscle pain because the rigididity. The muscles of the larynx, for instance, get a little bit rigid, one cannot speak well and all the difficulties that a Parkinson's disease patient has with their motor function. When that happens, then we need to take those cells that are acting irregularly and pace them again to the right way. That is why we call it neuromodulation; we are modulating them. We also call it a pacemaker for the brain because we are pacing those cells to work appropriately. We do that by giving a huge amount of electrical activity on top of them, so they quiet down. We overcome their ability to fire electrically because we give too much electricity in their place. It is high frequency electricity coming in a specific area of the brain that is out of control.

How do you get the electrodes in there?

Dr. DeSalles: We use simple mathematics to calculate, trigonometry. We use that to calculate where the electrode goes specifically in the area of the brain. We do specific MRI scans, very well directed to see those areas we need to see. We take the patient to the operating room with those images. Then, we get a guide frame attached to the patient's head. They are under anesthesia when we attach that frame so that we can guide the electrode. There is a mark that guides it precisely. In the operating room we take CAT scans of the patient with that frame in the head,. We merge MRI scans and CAT scans and we calculate the numbers, coordinates needed. We need to dial the numbers to our stereotactic frame, so that the needle goes in perfectly in that spot chosen. It does not depend on the shaking of the surgeon's hand or the patient's shaking the head. It does not matter, because the frame is attached to the patient's head and it is directly precisely to that point. Once the electrodes arrive there, we test it with electricity. We give electricity to the patients' brain and we see what happens.

Was Ernest awake?

Dr. DeSalles: Initially they are in the twilight zone because we do not want them to feel or suffer anything, so we can record the firing of the cells. We see that they are very hyperactive by recording what they are doing and then we wake up the patient. At this point, the electrode is in the proper position. The brain does not feel pain, so we can give electricity to the brain and the patient does not feel pain. The patient will feel the effect of that electricity in the brain. For instance, if I stimulate that spot and that spot is related to the hand, the hand will shake. 

FOR MORE INFORMATION, PLEASE CONTACT:

Antonio A.F. De Salles, M.D., Ph.D.
UCLA Medical Center
(310) 794-1508
BAddish@mednet.ucla.edu

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