Deep Brain Stimulation is considered one of the modern and innovative techniques in treating neurological diseases, especially Parkinson’s. This process is one of the advanced treatments that effectively improves the quality of life of patients suffering from advanced symptoms of this disease. In Turkey, recent years have witnessed remarkable development in the medical field, with the country becoming a major destination for many patients seeking effective and distinguished treatments at reasonable costs. This article comprehensively overviews deep brain stimulation to treat Parkinson’s in Turkey. It reviews the benefits, procedures, and successful experiences that make Turkey an ideal choice for patients worldwide.
Introduction to Parkinson’s disease and its stages of development
Parkinson’s is the second most common chronic neurodegenerative disease after Alzheimer’s disease, which is considered the first most common. It has a high incidence rate and is seen in 1-3% of the population over 65 years. Its incidence rate in males is more than 1.5 times that of females.
Research studies have linked theories related to the spread of Parkinson’s to environmental and genetic conditions. These theories suggest a relationship between Parkinson’s and chemical reactions, neurotoxins, and genetic predisposition.
The loss of dopaminergic neurons in the brain’s gray matter is considered the main cause of Parkinson’s. In addition, the imbalance of dopamine and acetylcholine levels in the basal ganglia also affects the development of Parkinson’s.
The main and early clinical manifestations of Parkinson’s include slow or inability to move, rigidity, and tremors at rest. At the same time, the late symptoms of Parkinson’s are postural instability, gait, and balance disturbances, which are progressive movement disorders (increasing with time).
The diagnosis of Parkinson’s is clinical and can be made using the UK Parkinson’s Disease Society (UKPDS) brain bank criteria. The main clinical features of Parkinson’s cannot be made) and a combination of muscle rigidity and tremor. And/or postural instability (not explained by visual, cerebellar, vestibular, or proprioception deficits).
Deep Brain Stimulation for Parkinson’s Disease in Turkey (DBS)
Although it is not possible to determine the exact cause of Parkinson’s, discoveries to treat the disease have constantly been evolving since there is no known cure, and the various approaches to treating Parkinson’s seek to manage the clinical manifestations rather than prevent or slowly the progression of the disease. Methods for treating Parkinson’s vary. Between medications, surgical procedures, behavioral therapy, or a combination of different treatment methods.
The main surgical methods in treating Parkinson’s are ablative surgery, deep brain stimulation Parkinson’s method, and transfer of embryonic mesenchymal cells to the striatum in the brain.
Many people with moderate to advanced Parkinson’s report poor quality of life despite optimal medical treatment due to variable response, bothersome dyskinesia, or unresponsive symptoms to levodopa treatment.
The main advantage of deep brain stimulation (DBS) for treating Parkinson’s is that the stimulation parameters can be adjusted based on the patient’s needs to improve results. Thalamic DBS is the most commonly used to control large-scale tremors in people suffering from essential tremors.
Deep brain stimulation for Parkinson’s (DBS) applied to the subthalamic nucleus (STN) or applied within the globus pallidus (GPi) are the most common target sites for DBS treatment in patients with disabling tremors and/or complications. Kinetics associated with levodopa.
Although deep brain stimulation (DBS) for the treatment of Parkinson’s is a proven therapeutic strategy, its success depends on an appropriate selection of cases and the experience and skill of the surgeon to increase the quality of results and reduce complications.
The age of a Parkinson’s patient is not an indicator of the outcome of deep brain stimulation (DBS) in terms of motor function, and similar improvement in this area can be identified in both younger and older cases. On the other hand, age is a related factor. Predicting beneficial effects on the quality of life of Parkinson’s patients.
Deep brain stimulation (DBS) techniques have been developed to treat patients with Parkinson’s disease over the past 40 years, and this has opened the door to developing treatment with this method in areas beyond movement disorder, such as pain, cognition, and psychological conditions.
Brain stimulation therapy can help people with Parkinson’s improve symptoms of tremor, stiffness, and slowness of movement. It can reduce the medication a patient needs to manage the disease.
Researchers who followed patients after surgery with deep brain stimulation (DBS) found that many of them continued to improve in their symptoms for several years after the operation and were able to eat, use the bathroom, and feed themselves. Also, patients who were treated for movement disorders with DBS may complain of, or do not complain of, changes in memory, thinking, or mood.
Deep brain stimulation for Parkinson’s (DBS) is reversible. It does not lead to permanent damage to brain tissue, and DBS can be better adjusted or programmed to suit the patient’s symptoms.
Mechanism of effect of deep brain stimulation for treating Parkinson’s patients (DBS)
Deep brain stimulation for the treatment of Parkinson’s is based on applying an electric field to cause stimulation in the nerve cell (especially the nerve cell axon), which leads to the opening and closing of sodium channels in the nerve cell membrane, thus generating action potentials and controlling the release of neurotransmitters. It is still unclear whether this mechanism is generally inhibitory or excitatory, and whether the effects are mostly local to the cell or at the neural network level remains to be determined.
There are four main theories to explain the mechanism of action of the brain stimulator in treating Parkinson’s disease:
- Direct inhibition of neural activity
- Direct excitation of neural activity
- Interruption of information
- Synaptic clearance
Although current theories about how deep brain stimulation works to treat Parkinson’s generally focus on immediate effects, there is evidence that deep brain stimulation may lead to synaptic and neural plasticity. There is also some evidence that it may lead to the formation of neuroprotection, synapses, and possibly protection of brain cells.
Criteria to qualify a patient for deep brain stimulation surgery in Parkinson’s disease (DBS)
Current German rules recommend that the following criteria are mandatory to consider deep brain stimulation for the treatment of Parkinson’s:
- Motor fluctuations, including symptoms of levodopa sensitivity or treatment-induced bradykinesia.
- Tremor that cannot be treated with medication.
- Reduction in levodopa-induced motor symptoms of >33% Unified Parkinson’s Disease Rating Scale (UPDRS) score. Tremor can be ignored in calculating the rating scale because it may be refractory to levodopa treatment while still responding well to deep brain stimulation for Parkinson’s.
More restrictive admission criteria are recommended for patients with Parkinson’s who are not older than 60 years and have motor fluctuations for no more than 3 years.
Criteria that make a patient ineligible for deep brain stimulation surgery
- Unstable comorbidities (e.g., coronary artery disease, active septic infection, disabling cerebrovascular disease, malignancy).
- Neurobehavioral and psychiatric disorders (such as psychotic disorder, bipolar disorder, depression, severe personality disorder).
- Dementia is in the final state.
- Unconfirmed diagnosis of Parkinson’s.
- Significant enlargement of the cerebral ventricles or cerebral atrophy on MRI.
- Severe axial symptoms are refractory to levodopa treatment (dysarthria, dysphagia, postural instability, or gait disturbances).
- No functional disability.
- Inability to provide informed consent for surgery.
- Social or geographical difficulties in reaching the hospital for follow-up visits and programming of the stimulation device.
- Inadequate social support from family or caregivers.
The surgical procedure applied in deep brain stimulation to treat Parkinson’s disease
The anatomical position of the patient’s brain should be scanned by MRI as a prerequisite to determine the target point and path for electrode placement used in deep brain stimulation to treat Parkinson’s.
After incising the skin and drilling a hole that gives access to the planned path, fine electrodes are inserted step by step (each step 0.5-1 mm) or guided continuously along the planned path to perform deep stimulation.
The microelectrode recording (MER) procedure may help identify target areas through distinct activity patterns identified by spontaneous firing, spike discharge, and activity changes due to movement or sensory stimuli. It thus may increase the accuracy of the final electrode placement of the MER procedure.
Relatively low thresholds for side effects characteristic of DBS to treat Parkinson’s, such as tetanus-like contracture due to internal capsular stimulation, can help determine the proximity of anatomical areas responsible for DBS side effects. Conversely, low thresholds indicate beneficial effects. Without developing side effects in deep brain stimulation for treating Parkinson’s, the preferred location for placing the electrode is determined. Once the optimal target is determined, the deep brain stimulation electrode is finally inserted.
Patients undergoing deep brain stimulation surgery for awake Parkinson’s can enjoy faster improvement and better outcomes, especially with symptoms such as dysarthria, as they can be easily detected during test stimulation during surgery, allowing better decisions to be made about final electrode placement.
The process involves placing three parts in the body, all implanted under the skin. The first part is the electrodes that enter the brain, the second part is the battery pack (or generator) placed in the chest just below the collarbone, and the third part is the wires connecting the electrodes to the battery.
Patients’ responses to deep brain stimulation vary from patient to patient. Results are often observed soon after initial stimulation programming. Adjusting deep brain stimulation settings for maximum benefit may take several visits, and they can be continually updated as symptoms change over time.
Implanting the electrodes takes a few hours and involves two stages. The first stage involves placing the electrodes in the brain, and the patient needs to spend a night in the hospital. During the second stage, the battery is implanted, and the patient usually returns home on the same day.
Depending on the patient’s condition, it may be possible to reduce medications. However, deep brain stimulation is most beneficial when used with medications and other treatments because it can reduce medication doses and side effects while still getting the same benefits.
Complications or risks of deep brain stimulation to treat Parkinson’s disease
Deep brain stimulation surgery to treat Parkinson’s can result in risks and complications associated with the surgery. Intracerebral hemorrhage is the main surgical risk and has an incidence of about 1-2%, including minor bleeding. Seizures are also a risk for any supratentorial surgical treatment and occur with an incidence of 1%.
Drug complications – similar to those following any surgical treatment – can occur after deep brain stimulation in less than 2% and include deep vein thrombosis, phlebitis, pneumonia, urinary tract infections, and pulmonary embolism.
Some complications are directly related to the DBS device itself, including lead migration and breakage at a rate of 2-3% and infection in the device at a rate of 3-8%. Complications may also occur from electrical stimulation in DBS, depending on the location targeted in the DBS and the location. Anatomical pole and these complications range from cranial nerve deficits and motor symptoms to psychological disorders and autonomic disorders.
The mortality rate from DBS surgery for Parkinson’s is approximately 0.4% and is often associated with postoperative myocardial infarction and pulmonary embolism.
Patient rehabilitation after deep brain stimulation
Rehabilitation programs should aim to treat functional problems and prevent problems that will arise later. Starting a rehabilitation program in conjunction with treating the disease from the early stages may help avoid such problems that lead to dependence on others, inactivity, social isolation, and decreased quality of life.
The rehabilitation stage before deep stimulation surgery in Turkey
The first step in evaluating surgery with deep brain stimulation is to inform the patient and his family about possible complications, and it also includes an evaluation of balance, movement, tremor, rigidity, coordination, speech, hand functions, activities of daily living, surrounding environment, and device selection. Auxiliary to movement, the pre-DBS rehabilitation program aims to:
- Improving respiratory function and preventing complications
- Reduce hardness
- Reduce pain
- Maintain independence from others
- Improve flexibility
- Improve walking
- Increase the level of coordination and gross motor balance
- Education and guidance on caregiving needs.
Postoperative rehabilitation phase
Stimulation patients are evaluated in the first 24 hours after battery adjustment. Parkinson’s patients experience respiratory failure due to hunched posture, kyphosis, and rigidity. Physical therapy begins with respiratory exercises, chest extension, and postural alignment exercises, effectively increasing respiratory capacity.
The patient must be taught correct posture to reduce postural disturbances and balance problems, and postural extension exercises and trunk rotation movements must be applied.
To prevent falls, the patient must be directed to rotate around a large arc by placing the foot correctly and increasing visual and verbal stimuli while walking. Walking should also be taught in rhythm and proper walking with arm rotation to prevent freezing. It is important to rest frequently during exercises and avoid excessive fatigue.
Recommendations for the patient and family after deep brain stimulation
After surgery, patients should refrain from the following activities:
- Excessive neck and neck massage and exercises.
- Performing upper limb activities above head level.
- Carrying a weight exceeding 3-4 kg in the first month.
- Some medical devices, such as magnetic resonance imaging, are used.
- Passing through electromagnetic gates (detecting devices at airports).
- Exposure to wireless waves because they pose a danger to the battery.
- Exposure to high-energy industrial machinery.
- Simple sporting activities can be performed, especially those that do not pose a physical risk of collision and without touching the neck area or the nerve stimulation device.
Price of deep brain stimulation to treat Parkinson’s disease in Turkey
The price of deep brain stimulation to treat Parkinson’s in Turkey varies according to the type of center in which the operation will be performed. The cost in the state hospital is about 22 thousand US dollars. In comparison, the cost in private hospitals is about 27 thousand dollars, while it may reach 33 thousand US dollars in the best hospitals. Deep stimulation treatment center.
Sources:
- Ibrahimoğlu and Akyol. Early-term results of deep brain stimulation in Parkinson’s disease: a case report. Cukurova Medical Journal 2019;44:1499-1505.
- Jankovic J, Tan EK. Parkinson’s disease: etiopathogenesis and treatment. J Neurol Neurosurg Psychiatry 2020;91:795-808.
- Lee et al. Current and future directions of deep brain stimulation for neurological and psychiatric disorders. J Neurosurg 2019;131:333-342.
