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Parkinson s Disease: Device Aided Therapies Jawad A. Bajwa, MD - - PowerPoint PPT Presentation
Parkinson s Disease: Device Aided Therapies Jawad A. Bajwa, MD - - PowerPoint PPT Presentation
Parkinson s Disease: Device Aided Therapies Jawad A. Bajwa, MD National Neuroscience Institute King Fahad Medical City Riyadh, Saudi Arabia Objectives Why to Consider Device Aided Therapies Which Patient Profiles are Best Candidates
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Six!
Deep Brain Stimulation Apomorphine Infusion Levodopa Carbidopa Intestinal Gel Infusion High Intensity Focused Ultrasound Gamma/Cyber Knife-Radiosurgery Thermal Lesion Surgery
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Why Intervene?
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Motor symptoms such as:
- Bradykinesia
- Rigidity
- Tremor
- Postural instability
Wearing-off
Non-motor problems, such as:
- Pain
- Autonomic symptoms
- Mood
Wearing off: the re-emergence of symptoms before the next dose of medication
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4 3 3 3 3 2 2 2 2 2 2 2 2 2 2 3 3 4 4 4 4 4 3 3 3 4 3 3 3 3 3 4 4 4 1 2 3 4 15 30 45 60 75 90 120 150 180 195 210 240 270 285 300 UPDRS Finger Tapping Score Time (minutes)
PD1
R L 3 2 2 1 1 1 1 1 1 1 2 1 1 2 2 2 2 2 2 2 3 2 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 2 1 1 2 3 4 15 30 45 60 75 90 105 135 150 165 180 210 240 255 270 285 300 315 330 UPDRS Finger Tapping Score Time (minutes)
PD2
R L 1 2 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 2 3 4 15 45 75 105 135 150 165 180 UPDRS Finger Tapping Score Time (minutes)
PD3
R L 4 3 3 2 1 1 1 4 4 4 3 4 3 3 1 1 1 4 4 4 4 1 2 3 4 15 30 45 60 75 105 135 150 165 180 UPDRS Finger Tapping Score Time (minutes)
PD4
R L
Medication giv en Medication giv en Medication giv en Medication giv en
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Clinical Parameterization
Inter-Patient Variability Intra-Patient Variability
MDS UPDRS Part-3 Many Shades of ON and OFF!
OFF ON
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Who to Consider
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Device Candidates
◼ Cardinal Symptoms ◼ Tremor, Rigidity, Akinesia/Bradykinesia,
Freezing of Gait
◼ Medical therapy “maxed out” ◼ Motor (ON/OFF) fluctuations ◼ Drug-induced dyskinesias ◼ L-DOPA response ◼ Age ◼ Rule out Parkinson’s-Plus syndromes
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Deep Brain Stimulation: General Concepts
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Deep Brain Stimulation
A new era for the treatment of neurological disorders To Improve quality of life Offer Hope for medically intractable patients
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Deep Brain Stimulation (Target/Symptom Specific)
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Indications of DBS
❖ Movement disorders ▪ Parkinson’s disease ▪ Essential Tremors ▪ Dystonia ▪ Other ❖ Chronic Pain ❖ Epilepsy ▪ Psychiatric disorders ▪ Depression ▪ OCD ▪ Tourrette’s syndrome ▪TBI ▪Cluster Headache ▪Addiction ▪Obesity ▪Dementia ▪Minimally Conscious State
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Amplitude: 1-5 V Rate: 80-180 Hz Pulse Width: 60-240 μs STN STN
Johnson, et al. (2011) Y
- uman’s
Neurological Surgery T extbook
Where We Are: Deep Brain Stimulation (DBS)
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- Team of Specialists
- Close Collaboration is
Essential
- Neurologist
- Neurosurgeon
- Neurophysiology
- Neuro-radiology
- Psychiatry
- Neuro-psychology
- Anesthesiology
- Bioethics
The Multidisciplinary Approach
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DBS for Parkinson’s Disease
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bA
Bajwa, JA. Johnson, M . Vitek, JL. Text Book of Functional Neurosurgery Lozano, AM 2008
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DBS Programming
DBS Programming ➢ Programming currently involves a trial process ➢Location, Location, Location ➢ Assessment of clinical benefits and side effect ➢ Adjustment of medications
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STN- DBS: Results
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Pumps
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LCIG Pump
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Apomorphine Pump
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Outcomes & Timing
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Being Practical!
Symptom specific and effectiveness: DBS vs LCIG vs Apomorphine Least Invasive and easy to do: Apomorphine vs LCIG vs DBS Patient Preference Cost
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Key Messages!
Keep in mind Window of opportunity Consider appropriate patient profiles Earlier intervention is an emerging consideration for well selected candidates (DBS) Future is defining PD syndromic heterogeneity and better biological phenotype clustering outcomes for device aided treatment
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