Deep brain stimulation (DBS)

Deep brain stimulation (DBS) is a surgical procedure in which the doctor places a neurostimulator (type of device) in the brain. This then delivers electrical signals to the areas of the brain responsible for movement, pain, mood, weight, obsessive-compulsive thoughts and waking from a coma. This makes it possible to treat Parkinson’s disease, chronic pain and epilepsy, among other things. Deep brain stimulation is only possible when classical treatment options fail. Although the installation of the system – which is often done in a few phases – is often safe, problems sometimes arise. Nevertheless, many patients experience relief from the original symptoms thanks to the deep brain stimulation.

  • Purpose of deep brain stimulation
  • Contraindication of placing a neurostimulator in the brain
  • Before the operation
  • To research
  • Medication
  • Just before the operation
  • During the surgical procedure
  • Phase 1
  • Phase 2
  • After the DBS procedure
  • Prognosis of deep brain stimulation
  • Risks
  • General anesthesia
  • Deep brain stimulation
  • Brain surgery

 

Purpose of deep brain stimulation

Deep brain stimulation can be used for patients with:

  • chronic pain
  • Parkinson’s disease (neurological disorder with tremors) when the symptoms cannot be controlled with medication. Deep brain stimulation does not cure Parkinson’s disease, but it reduces symptoms such as slow movements, walking problems, stiffness and tremors.
  • dystonia (uncontrolled or slow movement)
  • severe depression that does not respond well to medication
  • an obsessive-compulsive disorder / compulsive disorder
  • Epilepsy: Epilepsy surgery has usually already been performed first and only if this is unsuccessful or insufficiently effective, the patient may be eligible for deep brain stimulation.
  • essential tremor (tremors of unknown cause that cannot be controlled)
  • Tourette syndrome (disorder with vocal and motor tics) (rare)
  • Huntington’s disease (progressive neurological disorder)

Furthermore, DBS may be useful for the treatment of severe obesity, anorexia nervosa and addiction problems, but as of September 2020 the studies are still experimental.

Contraindication of placing a neurostimulator in the brain

This operation is riskier in people over 70 and in patients with high blood pressure and diseases that affect the blood vessels in the brain. The surgeon must then carefully weigh the benefits of the operation against the risks. If necessary, the surgeon is able to reverse the deep brain stimulation procedure. DBS has fairly minimal absolute contraindications. Deep brain stimulation is contraindicated in patients who cannot properly operate the neurostimulator. Once implanted, patients with deep brain stimulators should not undergo whole-body MRI scans, transcranial magnetic stimulation, and diathermy.
Components of the deep brain stimulation system
The deep brain stimulation system consists of four parts:

  • One or more insulated wires, leads, or electrodes, that the surgeon places in the brain
  • Anchors to attach the cables to the skull
  • The neurostimulator, which delivers the electrical current. The stimulator is comparable to a pacemaker. The surgeon usually places this under the skin near the collarbone, but sometimes he also places it elsewhere in the body.
  • In some patients, the surgeon adds another thin, insulated wire (an extension) to connect the cable to the neurostimulator

The surgeon performs surgery to place each component of the neurostimulator system. In adults, the installation of this system is done in one or two separate operations.

Before the operation

To research

The patient receives a complete physical examination. The surgeon orders many laboratory and imaging tests, including a CT scan or MRI scan. These imaging tests determine the exact area of the brain responsible for the symptoms. The surgeon uses the images to place the lead in the brain during surgery. Sometimes the patient also needs to see a neurologist, neurosurgeon and/or psychologist to ensure that the procedure is appropriate and has the best chance of success.

The doctor needs a list of medicines used for the operation / Source: Stevepb, Pixabay

Medication

The surgeon must be aware of any pregnancy, alcohol abuse, and any over-the-counter and prescription medications, herbs, supplements, or vitamins used. Sometimes the patient may need to temporarily stop taking blood thinners such as warfarin (Coumadin, Jantoven), aspirin, ibuprofen, naproxen and other NSAIDs (non-steroidal anti-inflammatory drugs). The surgeon also reports which medications or remedies the patient may still take on the day of or days before the operation. Smokers should stop smoking before surgery.

Just before the operation

The patient must also fast (not eat or drink) eight to twelve hours before the operation. He washes the hair with special shampoo just before the surgical procedure.

During the surgical procedure

Phase 1

Phase 1 usually takes place under local anesthesia (in children under general anesthesia). The surgeon then shaves off some of the hair on the head. The surgeon then places it in a special frame with small screws to keep the head still during the procedure. The patient is then given anesthetic medication where the screws come into contact with the scalp. Sometimes the surgeon performs the procedure in the MRI machine and there is a frame on top of the head instead of around the head. The surgeon then applies the anesthetic medicine to the scalp where the surgeon will open the skin, and then drills a small opening in the skull and places the lead in a specific area of the brain. When the surgeon treats both sides of the brain, he makes an opening on each side of the skull and places two leads. Sometimes he has to send electrical impulses through the lead to make sure it is connected to the area of the brain responsible for the symptoms. The patient may need to answer questions or describe images, or move their legs or arms when asked. This way the surgeon knows that the electrodes are in the right place and the expected effect is achieved.

Phase 2

Phase 2 is done under general anesthesia. The timing of this phase of surgery depends on the location of the stimulator in the brain.
The surgeon makes a small surgical opening (incision), usually just below the collarbone, and implants the neurostimulator. Sometimes he places this under the skin in the lower chest or abdomen. The doctor places the extension wire under the skin of the head, neck and shoulder and then connects it to the neurostimulator. He then closes the incision. The device and wires are not visible outside the body. Once connected, electrical pulses travel from the neurostimulator, along the extension wire, to the lead and to the brain. These tiny pulses disrupt and block the electrical signals that cause symptoms of certain diseases.

When a headache occurs after the surgical procedure, it is important to consult the doctor / Source: Geralt, Pixabay

After the DBS procedure

Patients usually stay in the hospital for about three days. The patient also takes prescribed antibiotics to prevent infection. During a follow-up visit, the surgeon activates the stimulator and adjusts the amount of stimulation.
If one or more of the following signs appear, contact the surgeon is necessary:

  • numbness or tingling on one side of the body
  • headache
  • itching or hives
  • fever
  • nausea and vomiting
  • pain
  • vision problems
  • problems speaking
  • redness, swelling or irritation at any of the surgical sites
  • muscle weakness

 

Prognosis of deep brain stimulation

Thanks to the operation, the symptoms improve in many patients, which increases the quality of life. Most patients still need medication, but in a lower dose.

Risks

General anesthesia

Some patients experience reactions to medications or breathing problems.

Deep brain stimulation

Deep brain stimulation is a safe and effective procedure, but there are always risks involved, such as:

  • concentration problems
  • dizziness
  • an allergic reaction to the deep brain stimulation components
  • a stroke
  • an infection
  • a leakage of cerebrospinal fluid, which may lead to headache or meningitis (meningitis with headache and stiff neck)
  • a loss of balance, reduced coordination or slight loss of movement
  • vision problems
  • jerky sensations
  • speech problems
  • temporary pain or swelling where the device is implanted
  • temporary tingling in the face, arms or legs

Furthermore, problems sometimes arise when parts of the deep brain stimulation system break or move, such as a defective device, a broken lead or broken wires, a failed battery, and sometimes require further surgery.

Brain surgery

Possible risks of brain surgery include:

  • a stroke
  • a blood clot or bleeding in the brain
  • a coma
  • a brain swelling
  • an infection in the brain, wound or skull
  • epileptic attacks
  • problems with speech, memory, muscle weakness, balance, vision, coordination and other functions, which may be short-term or permanent
  • confusion, which usually lasts for several days or weeks
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