Chapters Transcript Video Overview of the Clinical Aspects of Deep Brain Stimulation Good evening everyone. Thank you for joining us. My name is Isabel Henson and I am the special events coordinator here at T. G. H. And I will be your moderator for our webinar tonight. There are a couple of housekeeping things that I'd like to cover before we go ahead and get started. So this is an educational webinar. And if you are interested in claiming any C M E or C eu credit, I will email you within the next 48 hours with specific instructions on how to claim those credits. You have to stay logged in for the entirety of the program to claim those credits though next I would like to mention that we will be recording this webinar. Um it'll be posted on our website for later on demand viewing. However, it will just be of our presenter, Dr Flutie and the presentation. No names or other personal information will be recorded published or shared as for Q and A. Tonight we highly encourage questions and discussion to do this on your zoom. You can mouse over on the window and you'll see a Q and a or chat icon. You can type your questions comments here and they'll come to me and I'll go ahead and interrupt politely to dr flutie, who is really encouraging conversation, dialogue and questions tonight. We do not have a raise your hand feature. So typing in this chat area is the only way to communicate with us and now I'd like to turn it to dr z Hi everyone. Um nice to see you tonight. Um it is my honor to introduce dr Oliver flutie. Um He joins the neurosurgery program and our neuromodulation program last august and it's just been a tremendous asset to have him here. Um Dr Flutie received his doctor of medicine at the American University of Beirut. Um He was a neurosurgery resident in the University of Iowa. Uh did his epilepsy fellowship and University of Iowa and then did a functional neurosurgery fellowship for several months in Oxford and finally did a stereotype Actiq functional and epilepsy fellowship and University of Toronto where he worked with Dr Andreas Lozano. So it's my great pleasure to introduce this evening. Dr fluke. Thank you very much. Dr Z thank you everyone for joining us this evening for an exciting presentation on the clinical aspects of different simulation. My general style is informal. So if you have any question at any point, just type it in the chat box and Isabel probably will interrupt me. I'll be happy to address your question. Um So I'm a neurosurgeon, working at Tampa General Hospital on Davis Island um islands and I specialize in functional neurosurgery which is a sub specialty that involves neuromodulation or modification of neural circuits inside the brain and the spinal cord patients to enhance function and quality of life neuromodulation can be done by performing lesions in a network to disconnect abnormal activity or implantation of medical devices in the brain or the spinal board with the implication of restoring function or improving conditions such as pain, epilepsy, movement disorders etcetera. Now, in our presentation today, we will focus on DBS or deepened stimulation for Parkinson's disease. This is a discipline within our functional neurosurgery specialty which entails stimulating deep inside the brain using electrical cables. Let's see the slide. I don't know if you're seeing your slides. Um so this is a brief overview slide of what DBS looks like on the left side. We see a device called the stereotype stick frame. This is a highly precise device that serves as a GPS unit to help calculate the coordinates of our target structure inside the brain and guide our implanted electrodes precisely within one millimeter of our target structure. Once the electrode is in the target, electrical currents can be delivered to jam apparent networks that are causing typical motor symptoms of Parkinson's disease. For example, if it's brady chinese are rigidity, um etcetera. Tremor. So this is an example of a patient with tremor before and after. Deep brain stimulation on the left side. You see significant hand tremor on the right side that is near abolished After deep brain stimulation. And we see this rewarding activity almost all the time in our clinic and it's quite a life changing procedure. I'm sure many of you have seen it and this is what it looks like it looks like in our operating room to the left panel. You see the stereo tactic frame being assembled and calibrated uh and set to our target structure and typically uh we do this surgery away in order to map relevant structures around our target. But we can also do it asleep. And there are various other techniques that I can go into later. So after providing this brief overview on what DBS is, we'll proceed with today's presentation. So I'll be discussing the history of deep brain stimulation, patient selection and referral clinical consideration and target selection, as well as surgical consideration and future directions and innovation. The challenge with brain surgery is doing it while minimizing damage to the brain. So in the 1930s, while the Penfield came up with the Montreal procedure where he exposed large areas of the brain and manually electrically stimulated each area to look for safe sites to do either a lesion or improve someone's symptoms or theater corridor for the reception, either for epilepsy or etcetera. Now this was found to be challenging laborious procedure, which we still do nowadays, But when needed for small lesions. Uh the first human frame was developed in 1947 and it was adapted from an animal frame which was made by horses. So this was the animal frame initially. And this is the first human stereotype stick frame which surprisingly still looks very similar to what we do right now. And this is the earliest image of the frame in 1947. It was developed by a neurologist actually and a neurophysiologist Spiegel advises and this is an artist adaptation or rendition of the frame speaker, speaker and wise frame was primarily designed for psycho surgery at the time surprisingly, uh in the same year a surgeon by the name of tel Arad designed a unique stereotyped IQ apparatus that was specifically intended to permit implantation of electrodes for recording and stimulation in epilepsy. Now this heralded the era of stereotype Actiq functional neurosurgery where frame based stereotypes is allowed the use of neuro physiological recordings in conjunction with electrical stimulation for assessing and exploring brain power grids prior to leisurely supporting of mapping and electrical stimulation developed in parallel with lesions and continuing to gradually develop with chronic electrode implants, allowing for systematic and safe incremental reasoning until stimulation became a stand alone treatment modality in itself. As we see nowadays with cbs. It's also worth noting that the clinical methods used for recording and stimulation and thus leading to a lesion also progressed gradually where it first started in the acute setting. Where surgeons first implanted the electrodes did the recording and stimulation found a safe spot and then there's the lesion. But they realized that they can actually implant the electrodes for several days which gave them more time to do more detailed mapping. So we did sub acute recording and stimulation than the lesion. And then they realized actually they can go weeks to months and that gave them an advantage rather than making a single lesion. What they did is very small incremental lesions over time until they thought that the systems were well controlled. And finally, like nowadays we only do recording and stimulation and there is no lesion is required since stimulation itself jams apparent networks as I said and can provide relief of sentence. Um Let's see. I think there's a, we're skipping a slide. Okay, that's all right. Kind of. It is important to note that neuromodulation started first with psycho surgery followed by pain epilepsy and movement disorders. Several groups were working with this technology separately and independently to treat various neuropsychological conditions. And work often projects simultaneously in different regions of the world, but mainly in europe and the United States and to a lesser extent in japan. Um let's see. Uh So this is an example. I don't know, can can, can, can people hear the commentating or no, I don't know if anyone, so I can commentate if if nobody is listening. But uh back in the day in the fifties Delgado implanted electrodes in the bowl and connected it to a radio receiver uh and using uh the remote control. He was able to stop the ball in place at that time, saying that this was one way to control aggression using deep brain stimulation. And at the time it was thought that the electrodes were placed either in the cardiac region or the septal area Now for functional neurosurgery and movement disorder. This generally came after uh psycho surgery and pain. But with the with the earliest recorded pallidotomy for Huntington's career was was dating back to the 1950 actually. And in that specific case electrical stimulation was used prior to leisurely Micro electoral recording and stimulation for the autonomous with high frequency stimulation to treat tremor in Parkinson's disease was recorded as early as 1963 by all the facade. And in the 1960s, functionally surgery experienced a decline when Levodopa was introduced and it was thought that it was a medical drug. So referring providers became reluctant to refer Parkinson's disease patients to neurosurgeons since the new drug was perceived as safe, effective and inexpensive. Now, soon after its introduction, Levodopa quickly became the first time treatment for Parkinson's disease and it overshadowed functional procedures for 10-20 years. However, DBS re emerged when many patients treated with levodopa became refractory to medical management and experienced significant side effects from the medication and disease progression. Now, the earliest recorded permanent thalamic dBS implant was reported by bryce and Mitchell in 1980 where they implanted DBS second for secondary intention tremor associated with multiple sclerosis. And then, seven years later in 1987 benefit and his group in France implanted a unilateral permanent economic DBS system in a patient suffering from essential tremor who had already undergone V. I. Am listening on the other side, it was a success story and the main success behind it is benefits, collaborative and multidisciplinary approach, which combined with systematic analysis of efficacy and the standardization of the surgical technique and that ushered in a new area era in modern GPS, now Historically implantable pulse generator technology first appeared in Cardiology in 1950s. And then the success of the cardiac pacemaker sector allowed for the technological transfer to the spinal cord stimulator sector. And that's what that happened from the 50s to the 60s. And then it was only later on transferred to DBS. When the first permanent DBS generator implanted was adopted from the spinal stimulator system. And that was in the 1970s. Now, soon after it was realized that chronic stimulation might deliver equally effective treatments with less risk of complications when compared to open regional procedures. The earliest thalamic stimulation with permanent implants appeared in the 1980s and benefits. Multidisciplinary approach, standardized the technique and popular popularized it at the time. In the 1976. In 1976 the U. S. Congress passed a medical device amendment and granted the FDA authority of all medical devices. The role of the FDA at the time was to provide guidelines, oversight and assurances of reasonable safety and effectiveness of devices under investigation prior to release in the medical field, Mark. Now, while regulating medical devices, brought brought about an end to the era of unsupervised investigational news of DBS. On one hand, it also increased patient safety transparency of clinical efficacy and minimized practice of haphazard and unsafe human experimentation which plagued the the practice at the time. And it is notable that increased regulation, restricted research and slow down innovation. Also The FADA granted approval of the economic DBS for treatment of tremble in 1997. That means 10 years after benefits first implant in the 80's and then six years later the FDA approved the STN and G. P. I. DBS to treat the advanced medically uncontrolled Parkinson's disease. So those things take quite quite some time from inception to regular regulation. Now today it's about 15,000 implants that the DBS system takes place every year. And the global market size was valued at $1.2 billion us 2020. And it is projected to increase by 9% in 2028. And an increase in patient referrals as more and more neurologists open up. So this treatment modality is helping helping our field as we witness a renaissance in DBS for other conditions. To include various ailments such as O. C. D. Tourette syndrome, morbid obesity aggression, depression, addiction, Alzheimer's disease et cetera. So so this is a simple comparison where we can implant leads precisely in the brain using two different techniques. One is a frame technique where we can this is the old frame on the top left corner below it is our modern frame that we use in our oh our temper general. It's called the C. R. W. Frame so we can use the frame to guide the uh to guide the specific electrodes or to guide stimulation or recording etcetera or even create a lesion. But we can also do it without a frame especially asleep. So for instance we can do the surgery inside the M. R. I. Scanner where we use special ceramic and plastic cannula to put the brain precisely where we're electrode precisely where we want it to be. Do an M. R. I confirm its placement and then closed while the patient is still asleep. And here at Tampa General we have all the technologies we can do it either with frame without a frame in the M. R. I. Scanner or even robotically. This is the robot we have here at Tampa General the rosa robots. We typically reserve it for multiple leads such as for epilepsy cases for stereo E. G. Et cetera. But it can certainly be done for TVs as well. So we spoke about the history of DBS will move on to patient selection and referral which is mostly guided by by our neurology colleagues. So patient selection and referral uh is a multifaceted process and it involves neurology screening, neurosurgical evaluation, neuropsychiatrist testing, neural imaging etcetera and discussing contraindications to surgery of course. Now the neurologist is screening is usually done by an experienced movement disorder, neurologist where confirmation of the correct diagnosis is very crucial. Uh huh. What's also crucial is to ensure that all medical options are adequately depleted and it's important during that screening process to rule out secondary causes such as medications induced Parkinson ian like state or other causes of tremor or other causes of similar symptoms. And the neurologists are very experienced usually a movement disorder and royal just experienced using standardized scoring tools such as the U. P. T. R. S. And it's generally recommended for example, for the U. P. R. S. Uh score to be greater than 30 of medications With with an improvement of 30 on medication that the patient comes in, gets tested off the medication, Compive to score above 30 Of medication. And then we give them their medication and then if they improve their scores with the motor symptoms etc by 30%. Then we think that they are deemed as a as a potential surgical cancer. This is one of the earliest screening tools that we use ah for those patients in our workflow Now in my clinic, it's also important to verify the correct diagnosis and screen for potential red flags. So I usually typically look for other symptoms such as hallucinations, red behavior disorder, significant hyper formula or the station also stasis or medication, unresponsive freezing of day dysplasia etcetera. Just to make sure we have the right diagnosis and to rule out the makers of Parkinson's disease which potentially do not respond to dbs. We also uh I also like to verify that the patient is a good candidate for surgery to review the past medical history and comorbidities discuss the pros and cons of surgery and the details of the surgical technique as well as discussed the side effect of stimulation and complications of surgery for the neuropsychiatric testing. Usually uh those comorbidities can be critical in the decision making and surgical planning patients would come over with depression for example, or multi moderate cognitive impairment could do better with certain targets as compared to another. For instance, someone with cognitive impairment can get worse with sub thalamic nucleus dbs as compared with G. P. I. For instance. And in extreme cases where someone has severe cognitive impairment uh surgery might not be a good option for them. And we have seen that in our clinic a few times and neural imaging is I think it's crucial for for the procedure. Typically we ordered a preoperative M. R. I. And for many reasons. One is to rule out intracranial pathologies such as brain tumors, a VMS, previous strokes or anything that can interfere with the surgery itself or another diagnosis. Actually. We also I also want to make sure that they don't have very large ventricles. That makes the surgery more complicated because typically we'd like the electrodes to avoid the ventricles. Uh severe cerebral atrophy is a problem because the more atrophy there is the more likely there is a space above the cortex. When we implant the electrodes, there's more likely a chance of developing a bleed or there's more likely a chance of CSF laws and brain shift during the operations uh therefore a high resolution M. R. I. Is very important and we use it before surgery. So we can do direct anatomical target for planning. And once we determine where the target, we can calculate the coordinates using special software and we we take those coordinates and put them down in the frame and and target that specific area. We also obtained a CT scan to to obtain the bony anatomy, especially when the frame is placed so that we can merge it with the M. R. I. Um and often we order dopamine tomography scan or that's cap to make sure we have the diagnosis correctly. Now, what are the contraindications to surgery? You know, this is a very uh well tolerated surgery. Uh, but just like any operation, there are, there are contraindications to it. Most of the contra indications, luckily are soft contra indications that can be optimized such as advanced kidney disease. Advanced age will open these significant commercial with burden rarely we have absolute contraindications such as someone is on specific anticoagulants that cannot be with health, for example, due to heart conditions or you know, implants, etcetera. Or if the patient has an active infection, it's always preferable to treat the infection first. Prior to implanting any hardware or if there is any skin breakdown over the head or the chest region. Uh Those are typically absolute contraindications to surgery, but they can be managed and treated and the patient can be reconsidered moving on to the clinical consideration on the target selection. So the interplay between advances in medical devices, better understanding of neural natural science and improve surgical outcomes has led to widespread acceptance of functional neural surgery to treat various ailments of central nervous system to include movement disorders, pain, epilepsy, neuropsychiatric disorders and disorders of conscious increased referring. Provided provided awareness of this technology has helped propel this technology to become mainstream in many centers. It's it's attractive safety profile, particularly it's reversible nondestructive feature as an appealing attribute to many different providers. And studies have shown that DBS is an effective procedure with low side effects and complications profile. And if investigators have shown that the overall risk of DBS hardware related complication is acceptably low even in patients with advanced age. So what are, what are the complications that can happen with this type of surgery? Keeping in mind that any surgery comes with its risk profile. And if someone is here to undergo an appendectomy, there's a risk of complications as well. So, for this specific surgery, focusing on DBS today, those complications can take place in the very operative time period close to surgery or during the surgery or in a delayed fashion following implantation of the surgery, implantation. So the early very operative complications include interest, cerebral hemorrhage, that means inside the brain or subdural hematoma, air embolism can take place this kinetic storms, seizures, your lactic like malignant syndrome, acute postoperative behavioral and cognitive dysfunction. Which is which is which can be seen with dynamic dBS delayed complications. Of course we have hardware infection, skin erosion, delayed onset paralegal oedema, hardware failure. Side effects from stimulation and programming or psychiatry disorders such as this inhibition and apathy. Now for target selection. Typically for Parkinson's disease, there are two targets that we discussed. Usually it's either the subatomic nucleus or the global pilot is the internal segment but we can also target the V. I. Am nucleus of the thalamus for the coastal zone and sorta if it's restricted the tremor conditions. So it's like a tremor dominant party tremor dominant Parkinson's disease. So just to start with the sub thalamic nucleus you can see the picture on the right. It's a very small nucleus actually it's the size of a lentil and we have to traverse approximately 15 cm of brain and and be precisely within it because if we are a few millimeters away from it, we can induce significant side effects and it can cause a problem with the procedure and with the success of the surgery itself now stop thalamic nucleus is in a very effective target in reducing Trevor bradycardia. Asia and rigidity and it helps improve gate on sadness and freezing of symptoms if they are responsive two medications. Uh It's it's very effective in mitigating. This kind of asia mostly through reducing the number of medications And the number of medications can be decreased up to 50% in these patients. Uh And it can occasionally cause cognitive and behavioral adverse effects. Therefore the neuropsychiatric evaluation is very crucial. Typically it's recommended for patients with good cognitive reserve who are receiving a high dose of levodopa or dopamine agonists and experiencing significant side effects from the medical treatment. Because we're able to reduce the medication those and hopefully not cause any significant commode with cognitive side effects. G. P. I. Is slightly a bigger target. It's typically recommended in patients with cognitive dysfunction or mood disorders that is identified on preoperative neuropsychological screening. So GPT can also be considered for patients who suffer concomitant linda, Estonia or gait disturbances that are not responsive to education relatively. G. P. I. Has a lower cognitive side effects when compared to sub thalamic nucleus and it typically does not offer reduction in medication. So if someone is on a very high dose they are expected to stay on their titles and even increase their dozing as there disease progresses. Because as you know, dbs just helps with the symptoms of Parkinson's. It doesn't cure the disease itself. Finally the third target is less common in Parkinson's disease. Way more common in essential tremor for instance. And that's the V. I. M. Thomas and the caudal zona and sarah and for for for the sake of Parkinson's patients. It's usually reserved for tremor dominant P. D. And the and the we usually consider it when the traveler is a solely poorly controlled symptoms. Now the main side effects of targeting whether V. I. M. Or the zona answer to our speech and balance impairment. Which is more commonly seen if we do bilateral especially appealing in elderly patients with multiple comorbidities having fully controlled the unilateral dominant hand tremor due to low rate of complications with unilateral dBS expectations. And from a programming standpoint people argue that V. I. M. And zona and sorta programming is less cumbersome when compared to G. P. I. Especially STN dBS. So nowadays for example for the kalamata me for the V. I. M. Thomas targeting or the coastal zone codels. We can do that procedure uh in the M. R. I. In the M. R. I. Scanner. Uh We have that technology here at Tampa General if people are interested. So essentially the workflow is for this particular type of surgery which is the focused ultrasound. We have patients coming we put the frame on their head and we put them in the M. R. I. Scan after shaving their head. And then we use multiple beams of focused ultrasound onto a very small target in the brain. And those beams of ultrasound they will compound and create thermal lesion. Ah We don't need to perform any incision or plant any hardware. The patients come in in the morning, they leave after the procedure four hours later uh four hours later. And then we follow them up in clinic. So this is like an outpatient procedure And this is an example of of one of the procedures we've done in Canada prior to me arriving here. So essentially we we scan the patients, make sure they have the popular skull density for the procedure. And if they do we do the MRI target the lesion. And you can see to the right side where the arrow is. You can see a very small six millimeter target on the left side. And this was a patient we treated last Winter of Winter two years ago for for Trevor. And you can see on the on the upper upper hand upper panel, you can see there their handwriting with significant tremor which significantly improved after the procedure below on the spirals. Now, surgical consideration, what do we consider? Uh So it's important during the initial neurosurgical encounter to talk about all the details. We spoke about particularly the types of surgery, asleep versus awake. We talk about inter operative consideration and postoperative consideration. So in the initial neurosurgical outpatient encounter. Uh Usually we make sure we identify potential contraindications. Various details of surgery is discussed. Multiple targets can be discussed with the patient and the pros and cons of each target can be explained. We can also talk about advantages and disadvantages of available hardware. For example, we have linear leads versus leeds where we can steer the current or directional leads which are becoming more and more standard of care. Some people like rechargeable batteries or non rechargeable batteries. They just want to put one in and you know replace it every five years or so. I talk about different companies with different stimulation capabilities. Remote programming uh can be done nowadays as well over over over the internet. I also discussed the choice of incision, whether it's a long incision or small curvilinear incision, the type of anesthetic. Whether the general anesthesia or just local anesthesia and awake procedures or whether the entire procedure is performed in a single setting or the procedure is broken down two stages which I typically do here at Tampa general uh and patients like it. When we implant the electrodes first it takes about four hours and this is done awake And then we send them home, bring them back approximately 10 days later and then put the battery and the extension wire under general anesthesia where they live home the same day on the second stage. Uh inter operative consideration. The traditional standard for dBS surgery. And my preference most of the time is to perform the operation away with the stereo tactic frame inter operative micro electrode recordings and awake stimulation casting. This can be performed with a dedicated neurophysiology team to perform micro electoral recordings and physical examination by the movement disorder neurologist to evaluate the efficacy of stimulation effects and the side effect profile. Ah But there are frameless options available as well as a sleep techniques that we can do and can be performed entirely in the M. R. I. Suite as well as we discussed over here we have all the technologies so we can do any procedure we want whether it's a way or asleep, whether it's robotic, whether it's frameless or not. We can also use an inter operative ct scanner which which I can show you a picture of now post operatively for dbs uh those patients are admitted and the average hospital stay is between one and two days when we make sure that we didn't develop an acute side effects such as a lead or or any any side effects secondary to general anesthesia etcetera. And we obtained post operative imaging after surgery to make sure there is no complication. The lead is not in the wrong spot to confirm its location and to make sure that we don't have a hemorrhage etcetera. Now for the second stage procedure stage to patients go home the same day. Okay. Mhm. Uh and programming is approximately four weeks after stage one. So we we we bring them to our clinic. We do a multiple review of all the leads. We do detailed testing with medication adjustment as warranted, especially in sub thalamic nucleus cases. Now this is this is a typical workflow in in in in our hospital. So what we do is we put the patient in the frame and then we bring a ct scanner into the operating room and then we do the entire surgery inside the city scanner inside the operating room and after we implant the leads, we we have the luxury to scan them to make sure the leads are fine and the patient is okay before we close. And I find it as a very advantageous thing to do, which not all centers have by the way. Alright. We're getting close to finishing, finishing very early. So finally I'll talk about the future directions and innovations in this field. So there are many, many, many avenues that we can improve dBS. And right now, what's, what's really hard is remote programming where we're able to program someone remotely over the internet if they're having complications at home or something happened or if they're unable to attend our clinic due to the pandemic, we have the capability to do remote programming and that's restricted to a particular vendor, not all vendors at this time. And now the devices are becoming becoming more safe where most of them are very compatible. There is there is a future innovation and big data where people are using a large uh large number of MRI's and the neurophysiology data to explore optimal targets and stimulation parameters. You can use ai to stratify risk and predict the success of surgery. There is always there's also a lot of innovations in the hardware where they're compatible with different kinds of imaging the battery is uh undergoing miniaturize miniaturization and potentially criminalization where the battery will be attached to the lead if it's small enough people are also working on increasing the lifespan of the battery and potentially energy harvesting capabilities where they're able to harvest energy either from movement of the patient or electrical signals from the brain. There is also now now we can do independent current steering which is likely going to become a standard of care and we can increase our control over wave forms and different contacts with simultaneous recording. Even though it's not mainstream. Not many companies can do it. But for example one of the companies you can simulate different electrodes at different times with different settings and you can mitigate side effects or treat symptoms at the same time using this technology. And there's also talk about frameless technology with augmented reality and mixed reality platforms that's already being used in the hummus and the vascular fields of neurosurgery and hopefully it will move into movement disorders and epilepsy as well. Uh And and the thing that's ushering this innovation of course has increased computer power that's mixed with artificial intelligence which is causing more efficient closed loop systems nowadays where the for example for tremor the system can read the E. G. Signal whether from the cortex or deep structures in the brain and it will stimulate targets accordingly. So for example if someone is asleep there's no need for the battery to be active all the time. The system can shut off or if the patient is not having and really bad symptoms, the stimulation can be decreased. Mhm et cetera. So this is this is the final slide where it shows what we spoke about. So right now, the current DBS system where you see on the far left, it's comprised of an electrode which can be on one side or both sides, or multiple electrodes, which can target multiple areas in one patient and it provides typically continuous stimulation. That means the moment we activate the system. Typically, those patients are just being stimulated the entire lifetime of the battery. Uh and those electrodes are connected through an extension cable down to the to the battery, which is actually a computer that has a battery. Uh and it can be adjusted by a programmer right now and the battery lasts between 3-5 years depending on how much juice the patient is using. You know, the the higher the intensity of stimulation, the less the lifespan of the battery. To the extent that sometimes I tell my patients, especially trauma patients, that if they don't need it at night to turn it off so that they can prolong the lifespan of the device. Now, for the future of the DBS systems include an implantable pulse generator. People talk about smaller generators or even generators that are cranial. Ized to the dbs lead. Therefore Obviating the need of implanting extension cable and the battery in the chest. Um It can be connected to the internet, smaller longer battery life, rechargeable or energy harvesting. These are all talks but we still haven't had this technology yet. It is something that can be potentially developed within the next 5 to 10 years. The electrodes can can have multiple leads capable of sensing and stimulating and closed loop, adaptive or adaptive stimulation is already in order to be investigated without the need of extension cables. No battery, nothing. Yes, I have a couple questions for you. Okay, so my first one is can you go back and readdress how the beads are placed on the incision list surgeries. So thank you for asking. So in the incision incision list surgery, we don't even need to mm hmm. So this is usually reserved for patients who only have tremors. So whether it's essential tremor or tremor, tremor dominant, dominant Parkinson's disease. So what happens is the patients come in, we put them in the M. R. I. Scanner. We have an ultrasound machine that goes around their heads and it focuses all these ultrasound waves into a deep the target in the brain. So it traverses the scalp and it traverses the skull. It traverses the brain and those those beams are harmless on their own. But when they combine precisely to a 11 target, they will heat it up and create a leisure. So patients who who would like to explore this technology mainly have tremor dominant Parkinson's or essential tremor can undergo this procedure and potentially go home the same day. That's incredible. No, no electrodes needed. But it is still considered a surgery. We're still this is we're still creating a lesion. Like I don't want people to think that this is This is a surgery, this is a non surgery or a procedure that doesn't have complications. We can still have a small bleed in the area where people can develop this R three a or uh problems with gait, especially when they undergo bilateral bilateral reasoning, but it's very rare. And usually when they developed this artery are imbalanced, it's usually reversible, wow. Okay, so what are some other symptoms of Pd? And does it help besides the tremors? Usually it it helps with the cardinal symptoms of PD. That's a good question. So the tremor, brady Kinney Jha rigidity are are significantly mitigated by TBS. Now, the side effect of treatment for patients with prolonged Parkinson's who have severe dyskinesia. This can help as well, especially when the medication is reduced. A lot of PD patients also have problems with Estonia, for example, like dystonia. This can be mitigated with DPS as well. Um, gait freezing if it's responsible if it's responsive to medication. Can be, can be mitigated. Yes, as well. So pretty much all the symptoms, primarily all the motor symptoms of Parkinson's disease are very well controlled by dBS the psychiatric and other other problems with PD uh are typically not, well, three, unless they are responsive to medication. Okay, very good question. Back on the focus ultrasounds. What is the accuracy, accuracy and millimeters of the ultrasound beam lesion ng. Oh, it's it's it's the accuracy is probably submillimeter. Okay, that doesn't mean you can't develop side effects. That means we can we can choose a target and leasing this target in the submillimeter accuracy. Because we're in the M. R. I. Scanner because we can uh not to go into a lot of details, but we can do test test leisure in England. We don't create a lesion. But we hit the tissue minimally. Like a low grade fever. We hit the tissue to make sure that we have the right target and we make sure the patient doesn't have side effects when we stunned the tissue and then we do the leisure. So in terms of accuracy, it's very accurate. And how effective have you found these focused ultrasound treatments for essential tremor? Yeah, it's it's it's very effective. Uh You can you can help mitigate the lesion, the symptoms right away for Trevor only for tremor. I'm not talking about braddock Indonesia rigidity. I'm not talking about dyskinesia. I'm talking about Trevor. You can mitigate it within seconds of creating the lesions. And now this is a relatively new technology. Uh These patients have to be followed up over time because they can potentially have their symptoms re emerge as the disease progress. Unlike DBS, since we don't have a lead to increase the stimulation parameter or to adjust them, those patients can require additional treatments, but usually it's reserved for people who have comorbidities or they'll have advanced age or not interested in hardware and by far the vast majority of patients on the Gold Country. Thank you. Can you discuss direct directional ization and brain sensing? Yes. So these are these are two different things. So I wish I had a slide about it. So directional stimulation is where we can actually steer the current to the direction we want. Sometimes, for example, for the for the traditional electrode where you just have cylindrical electrodes, all you create is a cloud that looks like a almost like a sphere or a cylindrical sphere, if I may say. But nowadays those electrodes are broken down in a way where you can control them and create bubbles outside the electrodes and you can steer those bubbles in the direction you want. For example, if the patient is having a lot of motor symptoms with STN, you can steer the bubble posterior early. Or if the if the patient is experiencing significant sensory symptoms, you can steer, steer the current or the electric field materially to mitigate the symptoms. Uh and and and in my personal experience, I think uh this technology will be mainstream in a few years and people will only implant directional leads because of this advantage. Uh and because of its capability of mitigating side effects while providing similar, effective too. Now for the adaptive DBS. A few groups are working on it. Our group in Oxford are working on adaptive DBS for instance where they implant elite whether it's inside the brain or over the surface of the brain. And this lead is used for recording rather than than stimulation. And what they do is they record the E. G. The regular E. G. Signal or the EC O. G. Signal from that electrode. And the battery itself has a computer and that can be programmed to whenever it senses a specific neuro physiologic signature attributed to the symptoms that will increase its stimulation rather than stimulating the entire time. So that's one application for closed loop or adaptive DBS Or or for example if someone is standing up, they experienced freezing of gait. This might people might potentially program the computer where it can change its stimulation setting to accommodate walking. This is not a standard of care of course. And it's it's not it's not being used as a standard clinical method, but it's something that we look forward to in the very near future? All right. And then when on the treatment continuum, should patients start thinking about DBS? And is there a window of time after which it could be too late? Usually, usually. Uh I mean the neurologists know more than me. But typically uh we want those patients to be well established as Parkinson's disease. So they have to have been diagnosed for many years and been treated for many years and they should be responsive to medications and we should make sure they have Parkinson's and that's something else that mimic Parkinson's early on, such as multiple system, atrophy what other diseases. So my preference is to have the patients typically being treated for Parkinson's for many years which people are treated for many years with medications, they don't need surgery for it. And if many years later they became intractable to medications then we can consider surgery. But if they are responsible for medications then this technology is not for. And what was your second question? You have two questions for me. Is there a window of time after which it could be too late? No, there is no window of time. As long as they don't have absolute contraindications. Generally there is no window of time. I mean we don't want to implant patients who are 90 years old. But a very recent trial done by my mentor Dr. Lozano in Canada where they implanted alzheimer species. Those patients were in the late 80s. And it showed that the safety profile is very similar to the younger population scene and whether it's in Parkinson's or essential tremor. So so age itself is not a major contributing factor as long as we have, you know, good cognitive reserve, good co morbidity profile. Ah And if the patient is truly enthusiastic about the surgery to change their lives then then we can consider that. Yeah mindset is everything. I have a couple more questions in here. What are your targets for morbid obesity? Um Right now for morbid obesity. We don't do any any any TVs. There have been experiments for the lateral hypothalamus for example which are still ongoing and there is no clear evidence so far that it's it's it's it's effective or whether or not it is a standard by scare. So right now we don't do DBS for obesity but it's something that is on the horizon not only for obesity. I personally believe that the DBS will be the treatment modality for various other ailments not only opposite. And then how soon can patients be evaluated at this time? That's a very good question. So so our clinic we have we have a very efficient system here at the at our university. So we combine our neurology and neurosurgery visit in one in one In one in 1 visit essentially. So that if the patient doesn't have their neurologists they send them to us. Movement disorder neurologist. They send them to us and typically doctors Jesuits sees the patient and then I see the patient afterwards. We discuss it in the same day and then we talk to the patient. So it's all done in one package But we we we also treat patients for outside neurologists where their if their work is done and they've had their scores and you know the U. P. DRS etcetera the MRI's then then we can bypass and make it even more efficient. I don't know the exact waiting period to be honest. Especially nowadays with covid people are always canceling and we're always having having sudden open spots. So things can be very early. Like if you were able to uh to refer patients to us, we can see them very early within weeks sometimes and then the surgery is scheduled within weeks later, depending on insurance and paperwork and for evaluations who should people refer to. So that's a very good question. So for the evaluation, all you need to do if there is someone with Parkinson's disease that is poorly controlled on medications uh doesn't have a movement disorder neurologist for example, you can send them to us at the burdens. Um I think I have my, mm hmm. Sorry I'm controlling the presentation with my phone. So let's see if I get the slides. Yeah, I cannot control the slides anymore. Oh yeah, there you go. So I'm trying to go to the final slide. It has my email and dr Zitzewitz email on it. So, so, so maybe we can distribute the slide to interested people. We have my personal email or my assistant's email, Ariel Mitchell, She's the one who coordinates all this clinic evaluation and we have dr Zitzewitz email and we have the phone number. So all you need to do is probably fire an email to ariel Mitchell at a Mitchell dot USF dot e D U. And we'll take it from there ah from our, from our part we have all the capabilities to do everything. If the patient is intractable, you can send them to us and we can take it from there and if he has an outside neurologist we can still send them to them after we're done. If the neurologist once said like we're not going to keep the patient to us. Uh So it's all it's all a matter of communication. If you can send us the patient and tell us what you need we can do. We can take care of it, whether it's from the initial evaluation or just for surgery. Uh Typically the majority of patients who come to my clinic, they undergo the evaluation, the screening, the neuropsychiatric evaluation at our institute but sometimes they undergo it uh they undergo the screening at the outsiders and that's okay as well. And are you doing MG F. U. S at T G H now, that's it. So org fus is M. R. I guided focused ultrasound. So this is the one that I presented. We have the machine and it's going to be active. Well I think on 22 March and right now it's availability is very limited but but yes we do have we do have the machine. How exciting. Yeah, a couple more questions is dat scan before dbs a standard of care. Um No it's not usually. Uh and dr Zitzewitz can correct me if I'm wrong. Usually it's more preference for the neurologist, especially if they're suspecting if they're not sure it's a Parkinson's disease or if there are any red flags they can obtain it but I typically don't. And then can you elaborate a bit on how dbs remote programming that you had mentioned work works and does us F or T. G. H. Offer this also is an FDA approved. So. Yes. Yes and yes it's FDA approved and we do we do offer it. It's a very early technology so we're starting to work with it and it's I want you to know that typically neurosurgeons don't do the programming but in our institutions we we do the programming ourselves in in conjunction with our technology and we're starting to try this technology, it's a very very new technology and a lot of people who have already tried it before me have been very very satisfied. But for the initial initial evaluation after dbs it's always preferable to have the patients come by so that we can examine the incisions so that we can do the monopoly review and the extensive review early on so that the later sessions more brief and smaller sessions can be done remotely if possible. Now this remote capability is not offered by all companies. Ah only one company so far can allow us to do so? Alright and here's my last question um Have you had any surprises or useful insights from any near miss cases? Um I haven't I haven't uh but there are a lot of stories of insights from near misses. I mean the whole the whole field of uh CBS came from near misses but I haven't so far my my focus and my training is on standard clinical DBS. And so far I didn't have any major exercise. We've done DBS for as hybrids disease in Canada and we were able to control people's blood pressure through it. And we're potentially thinking about doing a big trial for blood pressure control using GPS. Very exciting, very exciting things Dr flutie. Do you have anything else that you'd like to share with the group? No that's pretty much it. That's my summary slide. So today I mean we learned about function neurosurgery specifically DBS for PD. And we talked about the advantages of TBS versus versioning and we talked about different electrodes at the workflow, different ways to extend the electrodes and future potential wow of this technology. And if anybody has any questions I'll be more than happy to. Yeah but if you flip back to that contact slide, Doctor Flutie we can leave that up until everybody exits so everybody can grab that information if they need it. But other than that I think this was a very insightful and educational CMI and I just want to thank everyone for joining us and thank you to dr floaty for your time this evening. And just as a reminder, I will be emailing you all with directions on how to claim your CMi or CPU credits within the next couple of days. So keep a lookout for that. But other than that, thank you from everyone here at T. G. H. And have a great rest of your night. Thank you everyone. Published February 11, 2022 Created by Presenters Oliver Flouty, MD Assistant professor Department of Neurosurgery and Brain Repair University of South Florida View full profile
