deep brain stimulation: a pacemaker for the brain€¦ · deep brain stimulation: a pacemaker for...
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Nader Poura*an, M.D. Ph.D. Director, UCLA Neuromodula4on Program
July 10, 2013
Deep Brain Stimulation: A Pacemaker For the Brain
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Goals of Neuromodula4on and Restora4ve Neurosurgery
Pa4ent-‐specific therapies Improve Quality of Life
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Historical “restora4ve” neurosurgery
Pioneers
Walter Freeman MD Psychosurgery
“Ice Pick” Lobotomy
Irving Cooper MD Movement
disorder surgery
AChA Ligation Cryosurgery
1953
Lars Leksell MD Stereotactic surgery
Pallidotomies Human Stereotaxy*
Gamma Knife *Preceded by Spiegel and Wycis
Eloquent treatments that universally required damaging the brain
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Advantages: (1) Reversible
(2) Modulatable
Current Practice: Deep Brain Stimulation
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Deep Brain S4mula4on
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• Preoperative Evaluation • Neurological • Pyschocognitive • Neurosurgical • General Medical
• Stereotactic Planning • MRI and/or CT
• Frame Placement – Frame or “Frameless” • Lead Implantation • Generator Implantation
• Programming
Multiple Stages of Surgery
2 - 3 months
1 day – 3 months
3-6 Months +
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Monopolar
Case (off or +)
2
1
0
3
1-, Case (+) 0-, 3+
Bipolar Contacts
Programming: Requires 3-6 months of visits
1. Amplitude (0-10 volts) 2. Pulse width (msec) 3. Frequency (130-185 Hz) 4. Electrode configuration
– Pseudomonopolar (-) – Bipolar (+-) – Guarded cathode (+-+)
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DBS for Movement Disorders: The Numbers
In the US…
650,000 people with Parkinson’s 100,000 people with dystonia
1.2 million people with essen4al tremor
180,000 poten4al surgical candidates
~100,000 pa4ents implanted with DBS worldwide
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Who’s a Good Candidate?
1. Diagnosis of tremor
2. Medica*ons have failed
3. Tremor Interferes with Quality of Life…
4. Medically suitable for surgery Able to tolerate a 3-‐6 hours of awake surgery
5. Realis*c expecta*ons and interest
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• DBS is not a cure • Not everyone is a good DBS candidate • DBS is only appropriate if the tremor is a major source of disability • DBS does not work instantly • DBS is part of a multidisciplinary management
scheme • DBS has three types of risks: Perioperative,
Equipment related, and Stimulation related complications
Patient expectations
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DBS: Beyond Movement Disorders using our knowledge of functional anatomy and brain mapping
Movement Disorders **Parkinson’s Disease STN, GPi **Essential Tremor ViM thalamus **Dystonia Gpi Tourette’s GPi, Thalamus
Psychiatric **Obsessive-Compulsive Disorder VC/VS Depression BA25, VC/VS
Pain Pain Thalamus, PVG Cluster headache Posterior hypothalamus
Epilepsy Non-lateralizing MTS Anterior nucleus of the thalamus
Others Alzheimer’s Disease Fornix Minimally Conscious State Thalamus Obesity Hypothalamus
** FDA approved
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Faculty Neurosurgery Neurology
Nader Pouratian, MD, PhD Yvette Bordelon, MD, PhD
Movement Disorders Neurology Jeff Bronstein, MD, PhD Indu Subramanian, MD
Leo Treciokas, MD Allan Wu, MD Ed Farag, MD Arik Johnson, PsyD
Carlos Portera-Cailliau, MD, PhD
Coordinators Heather Kubiszewski
Dolly West
Fellows Tasneem Peerually, MD Mark Stahl, MD, PhD