Friday, June 16, 2017
DEEP BRAIN STIMULATION (DBS) IN PARKINSON’S DISEASE
Major Symptoms of Parkinson’s disease
Parkinson’s disease (PD) is a progressive neurological disease, characterised by tremors, rigidity, slowness of movements and postural imbalance. Though it is more common after the age of 40, people younger than 40 can also get affected (when it is known as young onset PD).
Other symptoms of PD include low volume speech (sometimes totally incomprehensible), expressionless face, reduced blink rate, reduced arm swing while walking, stooped posture, small handwriting (called micrographia), short-shuffling steps, tendency to fall forwards. Many people also have pain and aches in the affected limbs. Sleep disturbance and restless leg syndrome are common comorbid illnesses in people with PD. Severe memory impairment is NOT a feature of PD, however, in advance PD, mild memory impairment may occur in about 10% of patients. Similarly, loss of bladder control or erectile dysfunction is not a feature of PD. When these features are present, one should suspect multiple system atrophy (MSA).
Diagnosis of PD
The diagnosis of PD is still best made on the basis of clinical examination by an experienced neurologist (preferably trained in movement disorders, though not a must). PET and DaT scans are available to help in the diagnosis of PD, but they are not superior to a good clinical examination by an experienced neurologist.
Treatment of PD
Treatment of PD is still primarily medical and DBS is not the first option.
The most effective medicine is levodopa-carbidopa combination. If a patient does not respond to levodopa treatment, we should doubt the diagnosis (it may not be PD). Even though levodopa is the most effective medication, we should delay starting it by 2-3 years, to avoid side effects and lack of efficacy later on. Other medications in use are pramipexole, ropinirole, trihexiphenydyl, selegiline, rasagiline, amantadine, entacapone, safinamide, etc.
Role of Deep Brain Stimulation (DBS) surgery in PD
DBS was approved for PD in 2002. In the past 15 years, about 1,35,000 patients worldwide have undergone DBS for PD.
What does DBS surgery involve?
A neurosurgeon places the leads (thin wires) that carry electrical signals to specific areas of the brain. Then, the surgeon places a battery-run neurostimulator (like a pacemaker) under the skin of the chest.
The surgeon may use a programming device to adjust the settings. You may have a device, similar to a remote control, which allows you to turn the system on and off and check the battery. You may also be able to adjust the stimulation within options programmed by your doctor.
A neurologist initially evaluates a patient to determine whether he or she is the right candidate for DBS surgery. Then, further evaluations include brain imaging (MRI, CT, PET, etc), neuropsychological testing, UPDRS scoring, etc. Once the patient is found to be suitable for DBS, he is referred to the neurosurgeon.
Which patients are likely to benefit from DBS surgery?
1. The diagnosis of PD should be definite.
2. Patient has had PD for five years or more.
3. Patient continues to respond to levodopa, even though the response may or may not be good.
4. There are motor fluctuations, such as on-off phenomena, with or without dyskinesia.
5. Various medical treatments have not had desired benefit.
6. PD symptoms are severe enough to interfere with activities of daily living.
Which patients are NOT likely to benefit from DBS surgery?
1. Patients with atypical Parkinsonian symptoms,
2. Patients with multiple system atrophy (where bladder and sexual dysfunction are prominent symptoms),
3. Patients with progressive supranuclear palsy,
4. Patients with dementia or severe cognitive impairment,
5. Patients with unstable psychiatric illnesses,
6. Patients with advanced PD, who are confined to bed/wheelchair; despite being on medications,
7. Patients with NO response to levodopa therapy,
Who are the best candidates for DBS surgery in PD?
1. Excellent response to levodopa therapy,
2. Younger age,
3. Mild or no cognitive impairment,
4. Few or no axial (affecting neck or trunk) motor symptoms,
5. Absence of or well controlled psychiatric disease.
Are there any complications of DBS surgery?
DBS surgery is generally safe if performed by a trained group of specialists. However, complications may occur in upto 3% of patients, which include:
1. Bleeding (hemorrhage) in the brain,
4. Speech impairment
5. Erosion, migration or fracture of the lead,
What to expect after DBS surgery?
Most patients report a reduction in severity of symptoms after surgery. Tremors, dyskinesia, slowness all respond to the surgery.
PD medications, however, can not be stopped even after DBS. Most patients still need to take medications, however, at much lower doses.
The benefits are seen at five years after surgery, however, the effect tends to wane in later years.
DBS does not alter the disease progerssion, and disease continues to get worse even after DBS.
Is MRI safe after DBS?
Yes, MRI can be safely done after DBS surgery.
What is the cost of DBS surgery ?
The cost of surgery is approximately INR 9,00,000 to 10,00,000.
Dr Sudhir Kumar MD (Med) DM (Neuro)
Senior Consultant Neurologist
Apollo hospitals, Hyderabad
Sunday, March 27, 2016
COMPARISON OF COST OF MEDICAL TREATMENT IN NEUROLOGICAL ILLNESSES (INDIA versus USA) (in US dollars; 1 USD=70 INR)
Neurologist consultation fees
CT scan charges
MRI scan charges
Long term EEG recording
Botox (One vial cost)
Hospitalization for acute STROKE treatment
The costs in India are that of private hospitals and diagnostic centers. Also, the discussion pertains to Neurology treatments in urban areas and metros of India.
Costs are exorbitantly high in USA
It is obvious that the treatment costs are several times higher in USA, as compared to India. I agree that insurance companies cover most of the cost in USA, but individuals still need to pay at least 10-20% of the bills. You can imagine the fate of those who do not have medical insurance (about 12% of Americans do not have insurance). In 2007, 62% of filers for bankruptcy in US claimed high medical expenses. US spends about 10,000 dollars per year per person on healthcare. About 20% of GDP is spent on healthcare. The medical treatment costs in the US are the highest in the world.
Waiting periods to see specialists/get procedures are long
In USA, there are long waiting periods to see a Neurologist, as well as, to get the procedures (EMG, EEG, Botox, MRI, etc) done. In India, one can see a neurologist, get the MRI done and get it reported by a Radiologist in a few hours! On the other hand, the average wait time to see a Neurologist in USA is 30-35 days. Getting the MRI done and its report would take several more days. The situation in UK and Canada are worse, where one may have to wait for 2-3 months to see a specialist and get an MRI done.
The charges are higher in several other countries too, including Singapore, Australia and Thailand.
Indian Neurologists are well trained and experienced
Regarding the expertise of Neurologists, training in premier Indian Institutes such as AIIMS, PGI Chandigarh, NIMHANS, CMC Vellore, Sree Chitra, Tiruvannathpuram, JIPMER Puducherry, etc are at par with the best in USA. The clinical experience of treating neurological illnesses is several times more among Indian Neurologists, simply because they see more number of patients. There are about 2000 neurologists to cater to 1.25 billion people (one Neurologist for every 6,25,000 people). In comparison, US have about 18,000 neurologists for a population of 320 million (one Neurologist every 18,000 people). On an average, Indian neurologists see 3-4 times more number of patients as compared to American or British Neurologists.
In summary, Neurological treatment costs are much lower in India as compared to US and many other countries. The access to Neurology care is easy, and has little or no waiting times. Neurologists in India are well trained in the subject and have a vast clinical experience.
DR SUDHIR KUMAR MD (Internal Medicine) DM (Neurology)
Senior Consultant neurologist
Apollo Hospitals, Jubilee Hills, Hyderabad
Friday, October 19, 2012
Botox Therapy for Chronic Migraine
What is migraine?
- Migraine is a condition, characterized by repeated episodes of headache.
- Headache can be on one side or both sides of head.
- Headache typically lasts for more than four hours, but usually resolves in less than 72 hours.
- Nausea (a sensation to vomit) or vomiting may be present during headache episodes.
- There may be photophobia (headache becomes more in bright light or sunlight) or phonophobia (headache becomes more in noise).
What is chronic migraine?
A person, who has been suffering from migraine, for a period of more than six months, is said to be suffering from chronic migraine.
What is the impact of chronic migraine on the sufferer?
Chronic migraine leads to a number of problems in the sufferer:
- Recurrent headache interferes with job or studies, leading to poor performance at work or in studies.
- It leads to frequent absenteeism at workplace or in college.
- People suffering from chronic migraine can not enjoy social functions, as slight triggers such as music can trigger the headaches.
- They need to avoid road travel, as it can trigger headaches.
- Patients are frequently forced to take multiple analgesics (pain-killers) every month, leading to significant adverse effects.
What are the treatment options for patients with chronic migraine?
Patients with chronic migraine, who get three or more than three episodes of headache in a month, require preventive therapy (medications to prevent repeated episodes of headache).
What are the commonly used medications to prevent headaches in a migraine patient?
Following medicines (with their brand names) are available for use in chronic migraine:
· Amitryptiline (Tryptomer)
· Flunarizine (Sibelium)
· Propranolol (Betacap TR, Ciplar LA)
· Divalproex (Divaa OD, Dicorate ER)
· Topiramate (Topamac)
· Botulinum toxin (Botox) injections
What are the disadvantages of oral medications?
1. Lack of efficacy- many people do not adequately respond to these medications. They continue to get recurrent headaches despite taking them for long periods.
2. Adverse effects- Significant adverse effects are noted with oral medications.
· Amitryptiline- drowsiness
· Flunarizine- drowsiness, weight gain
· Propranolol- aggravation of asthma, depression
· Divalproex- weight gain, tremors of hands, hair loss, pregnancy-related complications,
· Topiramate- tingling of feet, weight loss, glaucoma in rare cases, renal stones in rare cases.
3. Need to take them on a daily basis
What are the advantages of Botox injections over oral medications in migraine treatment?
1. Efficacy of botox in migraine has been proven in research and clinical practice.
2. Botox is fairly safe and the side effects are negligible.
3. Botox injections need to be repeated once in 3-6 months, so, the patient compliance is better and they can get rid of daily tablets.
Facts regarding Botox injections in a patient with migraine
· There are fixed points over the scalp, where the injections are given (irrespective of the site of head pain).
· These locations include front of head, over eyebrows, temple region, back of head and neck muscles.
· Injections are given by a neurologist, who is trained in the botox procedure.
· It is given by insulin syringe and needle, and is given in the superficial tissues (scalp muscles, which are hardly a few mm beneath the skin).
· Topical (surface anesthetic) creams are used, so, the injection does not hurt much and is almost painless.
· The whole procedure can be completed in an office (Outpatient) set up and is completed in 15-20 minutes.
· Patient can leave for office or home immediately after the botox procedure.
· A total dose of 155 units of botox is used in chronic migraine.
Are there any side effects of botox injections?
· This is the same botox that is used in cosmetic procedures and several million patients have received botox for neurological problems as well (such as writer’s cramp, dystonia, blepharospasm, post-stroke spasticity, hyperhidrosis, etc).
· It is among the safest injections, and has no serious side effects.
· Mild pain at the injection site may be felt (just as is felt with any injections).
· Mild bruising (and redness) and swelling may occur at the injection site.
· Mild eyelid droop may occur, which improves in a few days on its own.
My experience with Botox in migraine
- I see about 15-20 new cases of migraine per month, and have seen thousands of patients in the past 18 years of my medical practice.
- About 20-30% of them either do not improve with oral preventive tablets or they have side effects with them. Some people find it difficult to take tablets on a daily basis for a long period of time.
- For this group of patients, botox injection therapy is the most ideal. I see 2-3 patients per month, who are eligible to receive botox therapy in chronic migraine. About 1-2 per month receive them. In the past two years, I have given botox to about 40 patients with chronic migraine.
- About 95% patients report benefit after botox therapy and in most cases, oral tablets are not required after botox.
- None of them reported any adverse or side effects with botox.
I would like to share an interesting experience with one of the patients. Mrs Nazia (name changed) from
came in June 2012 for botox therapy in migraine. I gave her the injections on OP basis on the usual sites, including forehead. She had no side effects with botox. She came back for review three months later and reported that she was totally headache-free. However, she wanted a repeat botox injection. I was surprised. I asked her if she has no headache, then why does she want botox! She said, after botox, her husband has started to give her more attention and love, as her face has also improved (then, I realized that she wanted it for cosmetic effects). She also told me that three of her colleagues at her office want the botox to be given by me (but only for cosmetic reasons). I had a tough time, referring them to a cosmetic surgeon for the same. Dubai
If you want any further information regarding botox therapy in migraine, please email me at email@example.com
Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Senior Consultant Neurologist