Parkinson s disease a world of promise
1 / 23

- PowerPoint PPT Presentation

  • Uploaded on

Parkinson’s Disease: A World of Promise. Sarah Click Dr. Julie Gurwell Spring 2006. Background . Movement disorder Affects over 1 million people usually middle aged 2 nd most common ND disorder behind AD. Background cont’d. Progression due to loss of DA neurons in the brain

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about '' - lluvia

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Parkinson s disease a world of promise

Parkinson’s Disease: A World of Promise

Sarah Click

Dr. Julie Gurwell

Spring 2006


  • Movement disorder

  • Affects over 1 million people usually middle aged

  • 2nd most common ND disorder behind AD

Background cont d
Background cont’d

  • Progression due to loss of DA neurons in the brain

    • These neurons normally project into the striatum and eventually cause inhibition of the STN

    • Without them, there is hyperactivity of this portion of the brain that controls motor fxn

Background cont d1

Cardinal symptoms


Resting tremor


Postural instability

Standard criteria to diagnose is 2 of these

Other symptoms



Sleep disturbances

Psychotic symptoms

Decrease in balance performance and gait


Hypophonia (motor)

Background cont’d

Drug therapy reminders
Drug Therapy– reminders

  • Overall goal is to increase DA

    • Dopamine agonists

    • Inhibit breakdown

    • Anticholinergics

  • Limited long-term efficacy of drug treatment

  • Undesirable side effects

    • Dyskinesias


  • Three common

    • Thalamotomy

    • Pallidotomy

    • Deep brain stimulation

Thalamotomy and pallidotomy
Thalamotomy and Pallidotomy

  • Local anesthesia

  • CT, MRI, or ventriculography

  • Location is determined by stimulation with an electrode

  • Looking for the greatest effect on symptoms with the least amount of side effects.

  • Once target is identified, a lesion is made

    • This is permanent

    • Several lesions are normally made in different parts to maximize effects


  • The area targeted is the subthalamic nucleus (STN) or globus pallidus internus (GPi)

  • Procedure basically the same

  • Lesion not created

  • Electrode remains there

Why choose dbs
Why choose DBS?

  • Main goals

    • Increase motor functions

    • Increase ADL

    • Decrease need for levodopa

Stn dbs

Drapier et al. studied 27 patients that underwent bilateral STN DBS between 1999 and 2002

19 men and 8 women took part in the study

Goal was to determine quality of life before and after surgery

Inclusion Criteria

Age ≤ 75

Severe PD

Drug induced dyskinesias

Exclusion Criteria

Cognitive impairment

Marked cerebral atrophy on MRI

Major depression before surgery


Results of drapier et al
Results of Drapier et al.

  • Significant difference in the motor functions between pre-op off-med and post-op off-med/on-stimulation conditions with p<0.001

  • L-dopa dosage decreased an average of 29%

  • Quality of life increased by 21.1% at follow-up

Stn dbs cont d

Krause et al studied 27 patients that underwent bilateral STN DBS in 1997

Age range from 44-72

Symptom duration 7-25 yrs

Mean follow-up time ~29.8 months (range 23-55)

Goal similar to previous study

Inclusion criteria

Patients with advanced PD

Severe pharmacological side effects

Exclusion criteria

None listed

STN DBS cont’d

Krause et al results
Krause et al. Results

  • 3 patients lost to follow up due to

    • Intraventricular hemorrhage

      • Corrected by a temporary external ventriculostomy in which the lead was not replaced

    • Dysphagia and death

      • Patient had dysphagia before the surgery, stimulation made it worse, so it was turned off

      • Patient died of suffocation unrelated to surgery 1 ½ yrs later

    • No comment on last patient (not by me, by the researchers)

Krause et al results cont d
Krause et al. Results cont’d

  • Significant improvement in ADL, dyskinesias, and fluctuations post-surgery

  • Sig. imp. in freezing after 1 yr, stable for 30 months

  • Off-medication motor score significantly improved by 40-44% & stable

  • Motor score sig. imp. On-med/on-stim (p<0.04).

  • Tremor suppression much better with stimulation than with medication (p<0.05)

  • Stimulation improved rigidity and bradykinesia more than the medication alone could do in this trial, results stable


    • This caused a decrease in fluctuations and dyskinesias

Adverse events in krause et al trial
Adverse events in Krause et al. trial

  • Intraventricular hemorrhage (n=1)

  • Dysphagias (n=3)

  • Pneumonia (n=1)

  • Transient hyperhidrosis (n=6)

  • Moderate dysarthria (n=3)

  • Lasting hyperkinesias (n=2)

  • Increased falling (n=4)

  • Increased libido (n=1)

    • Maybe an alternative to Viagra?

      Note: most adverse events were related to amplitude and could be fixed if the IPG was turned down

Three other studies results
Three Other studies’ results

  • Sig. imp. in off-med scores by 39%

  • 42% reduction in dyskinesias

  • Reduction in L-dopa Equiv. dose by 24% (p<0.017)

  • Adverse Events:

    • Intracranial hemorrage (n=1)

      • Did not have to discontinue this study once resolved

    • Dyskinesias (n=1)

    • Paresthesias (n=1)

    • Apraxia of lid opening (n=1)

    • Mood change with apathy (n=1)

Pyschosocial factors in dbs
Pyschosocial factors in DBS

  • One study showed a suicide rate of 4.3%

    • Patients observed had PD, ET, primary and secondary dystonias, or MS-associated tremor

      • All but 1 were young men with a chronic neurological cond’n

      • Most had episodes of severe depression before or during the course of the disease prior to DBS, but only 2 had frank suicidal ideations or suicide attempts

      • Each of these patients showed significant improvement in their motor function following DBS surgery

      • No sig. changes in medications or other attributing factors to the lifestyle of the patients before each of the suicides

      • Need more extensive inclusion criteria

Pyschosocial factors in dbs cont d
Pyschosocial factors in DBS cont’d

  • Another study shows cognitive decline in patients post-op

    • Increased risk for cognitive impairment, without any early signs of dementia, in the elderly

    • Suggested there might not be enough neurologic reserve for the DBS to work in patients past a certain point

  • Also observed mental slowness

  • Medications were reduced in this study by 46% in the older patients and 47% in the younger, although they cited studies that showed medication reductions of up to 100%

Pyschosocial factors in dbs cont d1
Pyschosocial factors in DBS cont’d

  • Cognitive improvement observed in another study

    • No signs of suicide ideation (0/76 or 0% of patients for all you math majors!)

    • Psychomotor speed and working memory was sig. imp. with stim-on

    • No cognitive decrease at 1 year post-op in attention, construction, initiation, conceptualization, or memory scores


  • DBS is a great alternative to high L-dopa dosages

  • There are some side effects that should be considered before deciding to have the surgery

  • More emphasis should be placed on psychological function before approving the surgery

Getting support
Getting Support

  • American Parkinson Disease Association

    • 888-400-2732


  • National Parkinson Foundation

    • 800-327-4545


  • Parkinson’s Disease Foundation

    • 800-457-6676



1. Burch D, Sheerin F. Parkinson's disease. Lancet 2005;365:622-7.

2. Thiruchelvam MJ, Powers JM, Cory-Slechta DA, Richfield EK. Risk factors for dopaminergic neuron loss in human alpha-synuclein transgenic mice. Eur J Neurosci 2004;19:845-54.

3. Dewey RB, Jr. Management of motor complications in Parkinson's disease. Neurology 2004;62:S3-7.

4. Filali M, Hutchison WD, Palter VN, Lozano AM, Dostrovsky JO. Stimulation-induced inhibition of neuronal firing in human subthalamic nucleus. Exp Brain Res 2004;156:274-81.

5. Ferreira JJ, Rascol O. Drug-related sleep disturbances and Parkinson's disease: effects of dopaminergic antiparkinsonian drugs on sleep and wakefulness. European J Neurol 2000;7(Suppl. 4):26-35.

6. Nilsson MH, Tornqvist AL, Rehncrona S. Deep-brain stimulation in the subthalamic nuclei improves balance performance in patients with Parkinson's disease, when tested without anti-parkinsonian medication. Acta Neurol Scand 2005;111:301-8.

7. Hindmarch, I. Possible causes of daytime sleepiness with particular regard to patients with Parkinson's disease. European J Neurol 2000; 7(Supp. 4):9-14.

8. Deleu D, Hanssens Y, Northway MG. Subcutaneous apomorphine : an evidence-based review of its use in Parkinson's disease. Drugs Aging 2004;21:687-709.

9. Straits-Troster K, Fields JA, Wilkinson SB, et al. Health-related quality of life in Parkinson's disease after pallidotomy and deep brain stimulation. Brain Cogn 2000;42:399-416.

10. Yoshor D, Hamilton WJ, Ondo W, Jankovic J, Grossman RG. Comparison of thalamotomy and pallidotomy for the treatment of dystonia. Neurosurgery 2001;48:818-24; discussion 824-6.

11. Breit S, Schulz JB, Benabid AL. Deep brain stimulation. Cell Tissue Res 2004;318:275-88.


12. Esselink RA, de Bie RM, de Haan RJ, et al. Unilateral pallidotomy versus bilateral subthalamic nucleus stimulation in PD: a randomized trial. Neurology 2004;62:201-7.

13. Krause M, Fogel W, Mayer P, Kloss M, Tronnier V. Chronic inhibition of the subthalamic nucleus in Parkinson's disease. J Neurol Sci 2004;219:119-24.

14. Berney A, Vingerhoets F, Perrin A, et al. Effect on mood of subthalamic DBS for Parkinson's disease: a consecutive series of 24 patients. Neurology 2002;59:1427-9.

15. Drapier S, Raoul S, Drapier D, et al. Only physical aspects of quality of life are significantly improved by bilateral subthalamic stimulation in Parkinson's disease. J Neurol 2005;252:583-8.

16. Kulisevsky J, Berthier ML, Gironell A, Pascual-Sedano B, Molet J, Pares P. Mania following deep brain stimulation for Parkinson's disease. Neurology 2002;59:1421-4.

17. Minguez-Castellanos A, Escamilla-Sevilla F, Katati MJ, et al. Different patterns of medication change after subthalamic or pallidal stimulation for Parkinson's disease: target related effect or selection bias? J Neurol Neurosurg Psychiatry 2005;76:34-9.

18. Burkhard PR, Vingerhoets FJ, Berney A, Bogousslavsky J, Villemure JG, Ghika J. Suicide after successful deep brain stimulation for movement disorders. Neurology 2004;63:2170-2.

19. Saint-Cyr JA, Trepanier LL, Kumar R, Lozano AM, Lang AE. Neuropsychological consequences of chronic bilateral stimulation of the subthalamic nucleus in Parkinson's disease. Brain 2000;123 ( Pt 10):2091-108.

20. Alegret M, Junque C, Valldeoriola F, et al. Effects of bilateral subthalamic stimulation on cognitive function in Parkinson disease. Arch Neurol 2001;58:1223-7.

21. Pillon B, Ardouin C, Damier P, et al. Neuropsychological changes between "off" and "on" STN or GPi stimulation in Parkinson's disease. Neurology 2000;55:411-8.