Deep brain stimulation

Overview  

Deep brain stimulation (DBS) is a medical intervention in which a gentle electrical charge is directed to a precise area of the brain. This electrical current activates the neurons in that specific area, offering potential therapeutic benefits for various medical conditions. To reach the brain, this current is transmitted via one or more wires connected to a small implantable device positioned beneath the skin near the collarbone.

Reasons for undergoing the procedure   

Deep brain stimulation is a well–established therapeutic approach for individuals dealing with various neurological and psychiatric disorders, particularly when conventional medications fail to provide adequate symptom control. This innovative treatment has gained approval from the Food and Drug Administration (FDA) for several conditions, including: 

• Movement disorders: 

• • Parkinson’s disease 
  • Essential tremor 
  • Dystonia (including conditions like Meige syndrome) 
  • Tourette syndrome 

• Epilepsy: Deep brain stimulation has been authorized as an intervention for individuals with intractable or hard–to–treat epilepsy to reduce seizure frequency. 
• Obsessive–compulsive disorder (OCD): It has also been recognized as an effective therapy for medication–resistant OCD. 
• Investigational uses: Beyond these established applications, ongoing research is exploring the potential of deep brain stimulation in addressing various other conditions, including: 

• • Chorea (e.g., Huntington’s disease) 
  • Chronic pain management 
  • Cluster headache treatment 
  • Dementia symptom alleviation 
  • Depression management 
  • Addiction therapy 
  • Obesity  

Risk  

Deep brain stimulation (DBS) is generally considered a low–risk procedure, but like any surgery, it carries potential complications: 

• Surgical risks: Implantation of electrodes in the brain and a pacemaker–like device in the chest can lead to: 

• • Seizures. 
  • Stroke. 
  • Brain bleeding. 
  • Infection. 
  • Breathing difficulties. 
  • Nausea. 
  • Heart problems. 
  • Misplacement of electrode wires (leads).  

• Possible side effects after surgery: 

• • Headaches. 
  • Infection. 
  • Seizures. 
  • Confusion and difficulty concentrating. 
  • Hardware complications (e.g., eroded lead wire). 
  • Temporary pain and swelling at the implant site. 

• Side effects of stimulation: 

• • Balance problems. 
  • Speech difficulties. 
  • Lightheadedness. 
  • Numbness or tingling sensations. 
  • Muscle tightness in the face or arm. 
  • Vision changes (double vision). 
  • Mood changes (anger, mania, depression). 

It’s important to note that the device’s settings may need adjustments to minimize side effects, and there have been rare reports of DBS affecting swimming abilities, so consult a healthcare professional before swimming and prioritize water safety precautions. 

Before the procedure  

Before undergoing the DBS procedure, your healthcare provider will thoroughly discuss its pros and cons, as well as the associated surgical risks. They will assess your eligibility for the surgery, possibly requiring additional imaging scans or lab tests. 

If you choose to proceed with DBS implantation, your provider will arrange detailed magnetic resonance imaging (MRI) and computed tomography (CT) brain scans to determine the optimal electrode placement. 

Prior to the procedure, your provider will also address the following: 

• Medications: Your provider may advise discontinuing specific medications, like blood thinners, before the procedure. Always consult with your provider before making any medication changes, including vitamins and supplements. 
• Preparation and personal care: Expect instructions on how to prepare for the procedure, including the use of special skin preparation products or shampoos. 
• Fasting: Given the use of general anesthesia during surgery, your healthcare provider will instruct you to fast. This involves refraining from solid food for at least eight hours before the procedure and avoiding liquids for at least two hours prior. 

During the procedure 

Typically, this process comprises two to three separate surgeries performed at different times. 

• Brain surgery: Brain surgery for the placement of electrodes involves several key steps to ensure precision and safety. Initially, a specialized head frame, known as a stereotactic head frame, is secured to keep the patient’s head immobile during the procedure. Advanced neuroimaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) scans are then employed to create a detailed map of the patient’s brain. This mapping process helps identify the exact location within the brain where the electrodes should be positioned. 

In most cases, the electrode placement procedure takes place with the patient awake and alert. Local anesthesia is administered to numb the scalp, ensuring comfort during the surgery. Interestingly, anesthesia is not required within the brain itself since the brain lacks pain receptors. However, some individuals may opt for general anesthesia to undergo the surgery while asleep. The surgeon carefully inserts a thin wire lead with multiple electrodes at its tips into the specified area of the brain. In certain situations, two leads may be implanted, one on each side of the brain. These leads are then connected by a wire under the skin to a device called a pulse generator, which is typically implanted near the collarbone. Throughout the surgery, both the neurologist and the surgeon closely monitor the patient’s brain to ensure precise electrode placement and overall safety. 

• Chest wall surgery: In the second phase of the surgical procedure, the surgeon inserts the pulse generator, housing the batteries, beneath the skin near the collarbone. General anesthesia is administered to induce sleep during this step. Wires from the brain electrodes are carefully positioned beneath the skin, leading to the battery–powered pulse generator. A few weeks following the surgery, the generator undergoes programming during a scheduled appointment with a healthcare provider. Once programmed, the generator continuously emits electrical pulses to stimulate the brain, and you have the ability to manage its operation, turning it on or off using a specialized remote control. 

Prior to these surgeries, your healthcare provider will often place an intravenous (IV) line to administer IV fluids and necessary medications during the procedures as required. 

After the procedure 

Several weeks following your surgical procedure, the pulse generator implanted in your chest is activated, typically during appointments with your healthcare professional. The pulse generator’s settings can be adjusted externally using a specialized remote control. It may require multiple visits to fine–tune the settings, and it could take up to 4 to 6 months to discover the optimal configuration. 

The stimulation provided by the pulse generator can be continuous, running 24 hours a day. Alternatively, you might be instructed to deactivate the pulse generator at night and reactivate it in the morning, depending on your specific medical condition. You will receive a remote control to manage this, and in some cases, the pulse generator can be programmed to allow you to make minor adjustments at home. 

Most pulse generators are equipped with high–capacity batteries that have extended lifespans. Standard batteries in these devices typically last around three to five years, while some devices use rechargeable batteries that can last up to nine years. When it’s time to replace the battery, a shorter and quicker surgical procedure is performed compared to the initial implantation surgery. You will typically return home on the same day after a battery replacement procedure.

Outcome 

Your healthcare provider is the best person to inform you about your expected recovery time and when you’ll notice changes in your symptoms and overall well–being. The recovery duration can vary based on factors like your overall health, existing conditions, and personal circumstances. 

In general, the recovery period typically spans several weeks. Your healthcare provider will likely instruct you to undertake the following actions: 

• Hospital stay: After surgery to implant DBS leads in your brain, most people stay in the hospital for one day. The surgery to implant the pulse generator is typically a same–day procedure. 
• Recovery time: Overall, recovery usually spans several weeks. Your healthcare provider will guide you through the following phases: 
  • First two weeks: Avoid all activities, including household chores and sexual activity. Don’t lift anything heavier than 5 pounds (2.25 kilograms). 
  • Four to six weeks: Avoid moderate– to high–intensity activities, including exercise and physical labor. Most people can resume their regular routine after this period. 
  • Movement and stretching: Be cautious with certain movements, such as raising your arms over your head, for several days after the pulse generator implantation. Your healthcare provider will specify the duration of movement restrictions. 
  • Medical visits: Your healthcare provider will schedule post–procedure visits to monitor your progress and fine–tune your DBS settings. Neurologist appointments are crucial for optimizing settings without causing disruptive side effects. 
  • Regular checkups: Routine checkups with your healthcare provider are essential to monitor your condition, symptoms, and adjust medications or treatments as needed. The frequency of these visits will be discussed with you. 
  • Warning signs: Since DBS involves surgery, especially on the brain, it’s crucial to recognize warning signs. If you experience any of the following symptoms, contact your healthcare provider immediately or seek medical attention outside regular hours: 
    • Bleeding from your incisions. 
    • Fever of 38.3°C or higher. 
    • Sudden, severe headache or persistent headache. 
    • Signs of infection around incisions, such as redness, swelling, or unusual warmth.
    • Sudden changes in vision, like double vision, blurred vision, or loss of vision.