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Deep Brain Stimulation Surgery STN placement


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#1 trustandobey

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Posted 01 May 2013 - 12:20 PM

Hello,

My husband has had PD for 15 years as a young onset and is now facing surgery. His symptoms has been
Motor: Rigidity, freezing, a little dyskenisa, dystonia? ( snaking. now taking 1600 Sinemet and amantadyne.
Non Motor: Impulse control disorder/gambling: depression, anxiety, insomnia: anger etc. This has been controlled but not eliminated by fluvoxamine and clonozapine. recently, the DBS team learned a lot about him.. He was taken off Fluvoxamine and replaced by Wellbupropin and had negative complications and was hospitalized.. serotonin withdrawal symptoms.. slurred speech first, then hallucinations, seeing people/hearing voices ,delirious and then physically couldn't walk for a week or two..just now recovered..

Facing DBS surgery in May, STN placement.. bilateral but will be staged in two.. DBS team evaluatted him that he will be improved with his rigidity but maybe not freezing.. Non Motoer symptoms may be positively impacted too..

I'd like to get your expert perspective on target placement based on symptoms described above. Thanks.

#2 Dr. Okun

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Posted 01 May 2013 - 01:22 PM

This is a difficult case. At our center we always stabilize the mood and treat the ICD and behavioral symptoms to resolution before DBS. We usually get rid of dopamine agonists and use only sine met or a simple strategy. Sometimes we need clozapine, quetiapine, depakote or other agents to stabilize behavior. We have psychiatrists follow the patient with us pre- and post-op. We watch out for worsening. There is no guarantee that there will be med reduction post-DBS, and additionally that DBS will help the behavioral symptoms. My best advice is to stabilize the behavior before DBS, and also I agree to not have high expectations on med reduction, walking, talking, or thinking. Screen and monitor for depression and suicide. No one has the answer as to STN vs. GPi in these cases. STN may give more med reduction, but GPI may be safer....jury is still out.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#3 trustandobey

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Posted 01 May 2013 - 03:15 PM

Hi Dr. Okun,
Thanks for the fast reply. We are working with the doctors at Scripps Clinic Torrey Pines. in La Jolla, Ca. I heard that you recently visited the site and we are blessed to have good doctors and are connected to you. If I were them, I would ask for your expert advise and they may have already. I followed FLORIDA movement center and your website is robust and very impressive!! Yes, thank God that the non motor symptoms over the years was recently stabilized the past year or so and even with the recent episode, he is stable with the continued use of fluvozamine and clonozapine .. and he is taking 1600 mg of Sinemet and Amantadyne so I believe the DBS surgery is a go.
The consultation with a Psychiatrist I believe is very important, most especially after the surgery and even during the surgery.. I would be interested in hearing a confirmation of what is the general plan as to whether mind meds, fluvoxamine and clonozamine should or should not be stopped a day before the surgery.. knowing how my husband reacted when taken off completely ( not weaned off) from the fluvoxamine.

#4 trustandobey

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Posted 02 May 2013 - 02:50 PM

Hi Dr. Okun,

My husband is stable enough to be qualified for the DBS. He has seen a Psychologist this past year for general counseling and has helped stabilize the Non Motor symptoms of PD but he has not seen a Psychiatrist.
We were informed that he will be observed on his motor and non motor symptoms after DBS. Our wishes as a family of course is for my husband to take the least medication as much as possible and ultimately to be weaned of Non Motor symptoms medications . LIke you said, there is no guarantee on the results of DBS. Have you had patients with similar motor and non motor symptoms that were succesfully weaned off after the DBS surgery. Can integrative medicine help in the non motor symptoms especially?

Thanks .

#5 Dr. Okun

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Posted 02 May 2013 - 03:43 PM

We generally do not stop the psychiatric meds before surgery, but we do hold the PD meds for 12 hours before the incision. I like the idea of a psychiatrist. In our hands DBS usually doesn't solve behavioral issues, and it takes medications and therapy and an integrative approach to get at these often complex issues.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#6 trustandobey

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Posted 06 May 2013 - 10:08 PM

Hello again,
A follow up question on pending DBS strategy.
The DBS will be bilateral but will be staged. one side first, he will be observed and then evaluated for the 2nd surgery. 2 sides with 2 stimulators.
Do you agree with the staging?

Thanks.

#7 Dr. Okun

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Posted 07 May 2013 - 05:54 AM

Yes, staging is the safest method and in the NIH COMPARE study over 1/3 of patients long term did not require the second DBS device!
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#8 trustandobey

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Posted 07 May 2013 - 05:26 PM

Hi Dr. Okun,

Thanks for the responses. It has been very helpful. A follow up question on the treatment of non motor symptoms of PD. You mentioned medication, therapy and integrative approach in treating behavioural issues. The medication adjustment made within the past year.. taking out comtem and just sinemet, counseling through a Psychologist, strengthening his spiritual belief in God has significantly made improvement. DBS surgery is scheduled for May 13.. we will certainly watch out for behavioural changes, hoping not.
You therapy and integrative approach. Would you mind expanding on these two treatments.
I assume, we will need to see a Psychiatrist more actively.. ? I am also inclined to seek natural treatments through oure integrative medicine etc.
Which types of doctors are best to help my husband .. what background should they have? My best guess is to find ones similar to Dr. Ward in your clinic?...

Thanks again for all of these helpful information.

Emma

#9 Dr. Okun

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Posted 07 May 2013 - 07:58 PM

We like to use a psychologist, a psychiatrist, and possibly a social worker to help patients integrate with society and keep behavioral issues in check post-DBS. As for integrative alternative medicine approaches we support the families and patients in their preferences. We do like to use PT/OT/ and speech therapy.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips




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