What are the Causes and Factors of Epilepsy

Causes of epilepsy vary by age of the person. Some people with no clear cause of epilepsy may have a genetic cause. But what's true for every age is that the cause is unknown for about half of everyone with epilepsy.

• Some people with no known cause of epilepsy may have a genetic form of epilepsy. One or more genes may cause the epilepsy or epilepsy may be caused by the way some genes work in the brain. The relationship between genes and seizures can be very complex and genetic testing is not available yet for many forms of epilepsy. 
• About 3 out of 10 people have a change in the structure of their brains that causes the electrical storms of seizures.
• Some young children may be born with a structural change in an area of the brain that gives rise to seizures. 
• About 3 out of 10 children with autism spectrum disorder may also have seizures. The exact cause and relationship is still not clear. 
• Infections of the brain are also common causes of epilepsy. The initial infections are treated with medication, but the infection can leave scarring on the brain that causes seizures at a later time. 
• People of all ages can have head injuries, though severe head injuries happen most often in young adults.
• In middle age, strokes, tumors and injuries are more frequent.
• In people over 65, stroke is the most common cause of new onset seizures. Other conditions such as Alzheimer’s disease or other conditions that affect brain function can also cause seizures.

Common causes of seizures by age:

In Newborns: 

• Brain malformations
• Lack of oxygen during birth
• Low levels of blood sugar, blood calcium, blookd magnesium or other eletrolyte disturbances
• Inborn errors of metabolism
• Intercranial hemorrage
• Maternal drug use 

In Infants and Children: 

• Fever (febrile seizures)
• Brain tumor (rarely)
• Infections

In Children and Adults:

• Congenital conditions (Down's syndrome; Angelman's syndrome; tuberous sclerosis and neurofibromatosis)
• Genetic factors
• Progressive brain disease (rare)
• Head trauma

In Seniors:

• Stroke
• Alzheimer's disease
• Trauma
  
  
  When a disorder is defined by a characteristic group of features that usually occur together, it is called a syndrome. These features may include symptoms, which are problems that the patient will notice. They also may include signs, which are things that the doctor will find during the examination or with laboratory tests. Doctors and other health care professionals often use syndromes to describe a person's epilepsy.
  Epilepsy syndromes are defined by a cluster of features. These features may include:
  • The type or types of seizures
  • The age at which the seizures begin
  • The causes of the seizures
  • Whether the seizures are inherited
  • The part of the brain involved
  • Factors that provoke seizures
  • How severe and how frequent the seizures are
  • A pattern of seizures by time of day
  • Certain patterns on the EEG, during and between seizures
  • Brain imaging findings, for example, MRI or CT scan
  • Genetic information
  • Other disorders in addition to seizures
  • The prospects for recovery or worsening
  
  
  Not every syndrome will be defined by all these features, but most syndromes will be defined by a number of them. Classifying a person's epilepsy as belonging to a certain syndrome often provides information on what medications or other treatments will be most helpful. It also may help the doctor to predict whether the seizures will go into remission (lessen or disappear).

Advanced Epilepsy Treatment Options Available at World Best Hospital in India

How is Epilepsy treated?

The main line of treatment is with antiepileptic drugs, which are effective in controlling seizures in 70%-80% of patients with epilepsy. There are several antiepileptic medications. Since certain medications are much better for some seizures, the choice of the medication should be made by a physician who is familiar with these medications. If possible, the child should be evaluated in a center specializing in epilepsy. If this is not feasible, usually pediatric neurologists have training in epileptic disorders and are a good source for a referral.

When antiepileptic drugs fail to control the seizures, the patients may improve with surgical procedures.

Who is a candidate for epilepsy surgery?

Surgery is indicated in a small group of children.

It usually takes the failure of two or three antiepileptic medications before a child would be considered as a potential candidate for surgery. In general, this happens at least after two or three years of continuous treatment with medications. The failure might be due:

1.   to a resistance to the antiepileptic medications that are available,

2.   to the presence of intolerable side effects to the antiepileptic medication,

3.   or to a combination of both.

Since surgical procedures might be very effective in some children, once it is clear that the child's epileptic disorder is not responding to treatment with antiepileptic medications, surgery should be considered. Young age is not a contraindication for surgery, and there is no benefit in waiting for the child to be older.

In fact, there is considerable evidence that the younger a child is at the time of surgery, the better his/her potential will be for good function after the surgery. There is a certain degree of plasticity in the brain that helps with the recovery of functions that can be damaged at the time of surgery. This plasticity is higher in younger than in older children.

Advanced Epilepsy Treatment Options Available at World Best Hospital in India

Best Neurosurgery Hospital in India | Neurosurgeon India : Stroke Patient from Nigeria

Till the time a person develops a second seizure, treatment for epilepsy will not begin. This is due to the reason that a person may have one seizure and never develops a second seizure. Medicines are successful in treating epilepsy. These medicines do not cure epilepsy, they prevent recurring of the seizures. These medicines changes the chemical or electrical transmissions in the brain in a particle way that decreases the chance of a seizure.

Vagus Nerve Stimulation (VNS) :

VNS therapy is recommended when medicines are unable to control epilepsy. During the surgical procedure, an electrical device is implanted underneath the skin. The lead of this device is wrapped around one of the nerves on the neck’s left side. This nerve is called as vagus nerve. This device continuously passes an electric dose to the nerve in order to stimulate it. This process reduces the severity and frequency of the seizures. If a person is feeling a warning seizure symptom then extra stimulation is given for preventing recurrence of the seizure.

Ketogenic Diet :  This is also considered as one of the treatment for epilepsy. Ketogenic diet is recommended for children as it involves eating a diet which is low in proteins and carbohydrates and high in fats. The chemical balance of the brain can be altered that also reduces the chance of having seizures. Ketogenic diet is not meant for adults as the diet can result in any other serious medical condition like heart disease, high blood pressure or strokes.

Advanced Surgical Procedures for Management of Epilepsy

Depending on the particular clinical situation, one of the following surgical procedures is chosen by the Medical team at our affiliate hospital. These operations either aim to resect the disease area of the brain, to disconnect it from other areas so as to relieve the seizures, or to lessen their impact.

• Anteromedial Temporal Lobectomy
• Selective Amygdalohippocampectomy
• Electrocorticography guided Resections
• Multiple Subpial transections
• Quadrantic Resections
• Multilobar Resections
• Functional Hemispherotomy
• Vagal Nerve stimulation
• Radiosurgery (selected cases)
  
  
  
  
  
  For more information visit:          http://www.medworldindia.com       
                      https://www.facebook.com/medworld.india
  
  
  Please scan and email your medical reports  to us at care@medworldindia.com and we shall get you a Free Medical Opinion from India’s Best Doctors.
  
  
  Call Us : +91-9811058159
  Mail Us : care@medworldindia.com

Services offered at our Network Hospitals for the treatment of various types of Brain and Neurological Disorders

The neurologists and the neurosurgeons at our network hospitals in India take a multidisciplinary approach to care, using the latest research and technology. The modern surgical facilities at these hospitals include state-of-the-art dedicated operating rooms equipped for most advanced and latest intraoperative computerized tomography (CT) and magnetic resonance imaging (MRI) machines. The operating rooms are designed for both open and endovascular neurosurgery.

A lot of focus is given on new innovations that extend and improve medical care and patients' quality of life.

The expert team of neurologist, neurosurgeons and paramedical offers compassionate, world-class diagnosis and treatment for patients with all types of neurological problems like brain tumours, vascular diseases, movement disorders, epilepsy, chronic pain and traumatic brain injuries.

Our Network Hospitals in India use the most innovative technologies and latest research to deliver the best outcomes for our patients.

Services offered at ourNetwork Hospitals for the treatment of various types of Brain and NeurologicalDisorders

·         Highly advanced surgeries for the patients with Vascular Malformations, Cerebral Aneurysms, Complex Craniofacial Malignancies andAcoustic Tumours

·         Diagnosis and Treatment of Cancerous Brain Tumours with complete range of treatment options that include surgery, radiosurgery , radiation therapy, chemotherapy and other cancer treatments

·         Deep Brain Stimulation ( DBS) for patients with Parkinson's Disease and tremors from other neurological conditions

·         Paediatric neurologists and neurosurgeons who specialize in the surgical management of a wide range of paediatric diseases including brain tumours, epilepsy, spinal bifida and hydrocephalus

·         Minimally Invasive Brian Surgeriesusing the most sophisticated 3-D image-guided technology

Why should you choose ourNetwork Hospitals in India for Brain Surgery?

There are many reasons why so many patients from all over the world come to our network hospitals in India for various types of treatments related to Brain and other Neurological disorders. Following are the most common reasons.

Highly Skilled andExperienced Neurosurgeons and Neurologists

Our Network Hospitals in India have dedicated Neurology and Neurosurgery Department. The neurosurgeons operate with the most advanced technology systems. They use an image-guided management system for an improved perspective on the progress of complex brain surgeries. It can also help reduce the need for patients to undergo additional surgeries. The neurosurgeons have the expertise in Computer-assisted brain surgery, stereotactic radiosurgery, Awake Brain Surgery, Deep Brain Stimulation (DBS) and other complex surgical procedures related to brain and nervous system. They have been trained and have worked in some of the leading Brain Surgery Centres across the world. They work with a multi-disciplinary team of doctors that consists of neurologists, neuro-oncologists), neuroradiologists, orthopaedicsurgeons, ENT specialists, endocrinologists, general medicine and rehabilitation, pain medicine, and other areas to provide the most appropriate treatment for your condition.

Intraoperative Magnetic Resonance Imaging (iMRI)

The neurosurgeons at our network hospitals in India use a high-resolution intraoperative magnetic resonance imaging (iMRI) while performing brain surgeries. This helps them to see the brain tumours while performing surgery thereby greatly reducing the risk of damaging other parts of the brain. Moreover this also helps to confirm the successful removal of the entire tumour. The Intraoperative magnetic resonance imaging (iMRI) is used during the surgery to remove brain tumors and pituitary tumors with greater accuracy and safety. It is also used to place deep brain stimulator systems .

Computer-assisted Brain Surgery

In Computer-assisted Brain Surgery, various imaging technologies, such as Magnetic Resonance Imaging (MRI), Computerized Tomography (CT) and Positron Emission Tomography (PET) are used to create a 3-D model of the brain. The computer system precisely guides the neurosurgeon to the area/s of your brain requiring treatment. This helps the neurosurgeons to plan the safest way to treat your condition with greater degree of accuracy. The computer-assisted surgery helps a lot in performing Awake Brain Surgery. Computer-assisted techniques is also be usedin treating brain tumours and other lesions with precisely focused beams of radiation using stereotactic radiosurgery.

Stereotactic radiosurgery (SRS)

Stereotactic Radiosurgery (SRS) uses precisely focused radiation beams to treat brain tumours and other abnormal growths in the brain. The advantage of modern Stereotactic Radiosurgery is, it delivers high doses of radiation to the tumour with minimal exposure to surrounding healthy tissue. A multidisciplinary team of experts plan the treatment and carefully monitor doses to avoid the risk of radiation overexposure.Unlike traditional radiation therapy, in this treatment, no incision is made. This minimizes the chances of infection or excessive bleeding. A plan has to be developed before undergoing this surgery. A multi-disciplinary team of doctors plan an appropriate treatment for you depending on thetype of tumour, location and size.

Awake Brain Surgery

In an Awake Brain Surgery you're awake during the surgery. Awake Brain Surgery is done by expert brain surgeons to treat some brain conditions such asbrain tumors or epileptic seizures. Awake Brain Surgery allows yourbrain surgeon to work directly with you in order to locate critical functional tissue of the brain. This process is called mapping. Once the brain has been exposed, you will be awakened and the brain is stimulated to determine the function of each area of tissue. You may be awake during surgery to respond to your surgeon. Your responses will help the surgeon to ensure that he is treating the precise area of your brain that needs surgery. Awake Brain Surgery is mainly done if your tumor is near the parts of your brain that control movement or speech. Awake Brain Surgery helps in lowering the risk of damage to functional areas of your brain. In Awake brain surgery the important areas of the brain can be avoided and preserved during surgery.

Minimally Invasive Brain Surgery

Minimally invasive brain surgeries are commonly done at our network hospitals in India. The hospitals have expert surgeons who specialise in minimally invasive brain surgery techniques. In a minimally invasive brain surgery , the brain surgeons insert two small tubes and use what are called endoscopes. One tube carries a fibre optic camera and light source, the other carries miniaturized surgical instruments. The surgeons operate by watching a TV monitor.

In the traditional way of doing a brain tumour surgery, a more invasive approach was used to remove tumors close to the brainstem. The surgery took much longer time and was performed through an incision behind and below the ear. This took hours of bone drilling to reach the tumor. Since it was an open surgery, the risks were more. Nowadays, with the development of technology and expertise, some of the brain surgeries can be done through nose. The technique is called the endoscopic expanded endonasal brain tumour surgery. 

This technique allows neurosurgeons to pass a camera and specialized surgical instruments to the back of the nasal passage and directly to various regions of the skull base, without scarring and with a shorter recovery. Even though this technique was first described decades ago for pituitary tumor surgery, but recent advancements have helped to use the endonasal approach to safely remove tumors in a variety of other critical skull-base locations. There are very few surgeons in the world who have the expertise to use this technique in brain tumour surgery. At our network hospitals in India, you will find some expert neurosurgeons who have successfully performed many brain tumour surgeries using this technique. Some of the benefits of Endoscopic TransnasalBrain Tumour Surgery are No Brain Retraction, Faster Recovery Time, No Facial Scars, Fewer Complications and shorter Hospital Stays.

Advanced DiagnosticFacilities

Our network hospitals in India provide sophisticated diagnostic services for diagnosing or detecting a wide range of brain and other neurological disorders and conditions. Some of the advanced diagnostic facilities available at our network hospitals in India are as follows.

·         

  Electroencephalograms (EEG): Electroencephalograms or EEG is a non-invasive diagnostic procedure that is done to study the electrical activity of the brain. Electroencephalograms or EEG helps to diagnose seizure disorders, stroke, headaches, dizziness and fainting episodes.

·        

     Evoked Potentials: Evoked potentials studies help to measure the electrical signals along nerve pathways.Evoked potentials studies are used to diagnose visual losses, hearing losses, and nerve damage or degeneration within the spinal cord or nerve roots.

·         

    Nerve Conduction Studies: Nerve conduction velocity test measures how quickly electrical impulses move along a nerve and it is often done with electromyogram to exclude or detect muscle and nerve disorders.

·         

        Electromyography: Electromyography is used diagnose neuromuscular disorders such as Motor Neuron Disease, neuropathy, nerve damage and muscle damage.

·         

      Brain Suite System: To treat complex neurosurgical casesefficiently and safely, our network hospitals in India are equipped with an advanced Brain Suite System. The Brain Suite System allows high-resolution MRI images to be taken while performing the surgery. This helps the brain or neurosurgeons to remove complex tumours without harming the critical brain tissues.

·         

    Flat Panel DSA with 3D technology: This diagnostic technology provides high-resolution 3D images. You will have a much decreasedexposure toradiation.

·         

     Other Diagnostic Facilities: Isocentric C Arm,Neurophysiology Laboratory, Cerebral Angiography, Computed Tomography Scan (CT Scan), Intracranial pressure monitoring, Lumbar puncture, Magnetic Resonance Imaging (MRI), Myleogram, NeuroHisto Pathology, Pathology, Transcranial Doppler, Support Services, 1.5 T MRI ,64-slice CT facilities, functional MRI, MRI spectroscopy, diffusion/perfusion MRI etc.

For more information visit:          http://www.medworldindia.com     
                    https://www.facebook.com/medworld.india

Please scan and email your medical reports  to us at care@medworldindia.com and we shall get you a Free Medical Opinion from India’s Best Doctors.

Call Us : +91-9811058159

Mail Us : care@medworldindia.com

What causes Epilepsy? - Low Cost Epilepsy Treatment in India

What causes epilepsy?

Causes of epilepsy vary by age of the person. Some people with no clear cause of epilepsy may have a genetic cause. But what's true for every age is that the cause is unknown for about half of everyone with epilepsy.

• Some people with no known cause of epilepsy may have a genetic form of epilepsy. One or more genes may cause the epilepsy or epilepsy may be caused by the way some genes work in the brain. The relationship between genes and seizures can be very complex and genetic testing is not available yet for many forms of epilepsy. 
• About 3 out of 10 people have a change in the structure of their brains that causes the electrical storms of seizures.
• Some young children may be born with a structural change in an area of the brain that gives rise to seizures. 
• About 3 out of 10 children with autism spectrum disorder may also have seizures. The exact cause and relationship is still not clear. 
• Infections of the brain are also common causes of epilepsy. The initial infections are treated with medication, but the infection can leave scarring on the brain that causes seizures at a later time. 
• People of all ages can have head injuries, though severe head injuries happen most often in young adults.
• In middle age, strokes, tumors and injuries are more frequent.
• In people over 65, stroke is the most common cause of new onset seizures. Other conditions such as Alzheimer’s disease or other conditions that affect brain function can also cause seizures.

Common causes of seizures by age:

In Newborns: 

• Brain malformations
• Lack of oxygen during birth
• Low levels of blood sugar, blood calcium, blookd magnesium or other eletrolyte disturbances
• Inborn errors of metabolism
• Intercranial hemorrage
• Maternal drug use 

In Infants and Children: 

• Fever (febrile seizures)
• Brain tumor (rarely)
• Infections

In Children and Adults:

• Congenital conditions (Down's syndrome; Angelman's syndrome; tuberous sclerosis and neurofibromatosis)
• Genetic factors
• Progressive brain disease (rare)
• Head trauma

In Seniors:

• Stroke
• Alzheimer's disease
• Trauma
  
  
  When a disorder is defined by a characteristic group of features that usually occur together, it is called a syndrome. These features may include symptoms, which are problems that the patient will notice. They also may include signs, which are things that the doctor will find during the examination or with laboratory tests. Doctors and other health care professionals often use syndromes to describe a person's epilepsy.
  Epilepsy syndromes are defined by a cluster of features. These features may include:
  • The type or types of seizures
  • The age at which the seizures begin
  • The causes of the seizures
  • Whether the seizures are inherited
  • The part of the brain involved
  • Factors that provoke seizures
  • How severe and how frequent the seizures are
  • A pattern of seizures by time of day
  • Certain patterns on the EEG, during and between seizures
  • Brain imaging findings, for example, MRI or CT scan
  • Genetic information
  • Other disorders in addition to seizures
  • The prospects for recovery or worsening
  
  
  Not every syndrome will be defined by all these features, but most syndromes will be defined by a number of them. Classifying a person's epilepsy as belonging to a certain syndrome often provides information on what medications or other treatments will be most helpful. It also may help the doctor to predict whether the seizures will go into remission (lessen or disappear).
  
  
  
  

Epilepsy in Children - Best NeuroSurgery Hospitals in India

Epilepsy is a type of brain disorder which leads to a sudden change in how the brain works. It can cause people to have repeated (several or many) seizures called epileptic fits (convulsions), for short periods of time. The seizures happen because there is an uncontrollable electrical discharge from the nerve cells in the brain. This may create a short term disturbance in the way the brain works and cause odd sensations and abnormal movement or behaviour.

Epiliptic seizures are not usually dangerous. But, a person can be at risk if they are in a dangerous environment (eg swimming in a pool or beach, driving a car), or if they become unconscious. Injuries can happen at school, at work, at home or other places.

One child in every 20 will have a seizure during their childhood, often with a high temperature (febrile convulsion). This is not epilepsy. Most children who have febrile convulsions do not go on to have epilepsy. Only about one in 200 children have epilepsy.

Children with epilepsy can usually lead a normal and active life but will need to take be careful with certain activities.

It is important to know what to do and how to help your child if they have a seizure.

Signs and symptoms

The symptoms of the seizure depend on what parts of the brain are affected. What happens during a seizure lets doctors know what parts of the brain are involved.

Signs and symptoms may include:

• Sensory disturbances - is when you/your child experiences tingling, numbness, changes to what you/your child sees, hears or smells, or unusual feelings that may be hard to describe.
• Abnormal body movements - limp, stiff or jerking movements that may come with loss of consciousness and shallow or jerky breathing
• Abnormal behaviour - is when you/your child may be confused or have automatic movements such as picking at clothing, chewing and swallowing or appearing afraid
• All of the above

Types of seizures

There are many different types of seizures and they can be generally classified into two groups:

Focal seizures

Focal seizures happen when the seizure activity begins in only one part of the brain. It usually affects one side of the body and you/your child may or may not lose consciousness.

These include:

• Simple partial seizures
• Complex partial seizures

Generalised seizures

Generalised seizures happen when the seizure activity begins all over the brain. The person's conscious state is always affected.

These include:

• Tonic-clonic seizures, sometimes called 'grand mal' or major seizures.
• Absence seizures, sometimes called 'petit mal' or starring seizures.
• Myoclonic, atonic and tonic seizures.

Diagnosis of epilepsy

It is important that your/your child's epilepsy is correctly diagnosed and treated by a children's doctor (paediatrician) or a doctor who specialises in childhood disorders of the brain (paediatric neurologist). To diagnose epilepsy the doctor will need a very detailed description of your child's seizures, medical history, development, learning and behaviour. A home video recording of your child's seizures is very helpful if they happen often or are predictable.

Tests

Special test are needed in some children with epilepsy. Your child's doctor will talk to you about the following tests if they are needed.

• Blood tests:to check your child's sugar, calcium, magnesium and salt levels.
• EEG:is a recording of brainwave activity. (More information on EEG factsheet).      
• CT or MRI:gives us pictures of the brain. (More information on MRI or CT factsheets).
• Video EEG monitoring:detailed EEG done in hospital. (More information on Video EEG monitoring factsheet).

What causes epilepsy in children?

Many different disorders of the brain may be associated with epilepsy.

For some patients the epileptic disorder is congenital, that is, the child is born with the predisposition to have epilepsy. In other patients, the epileptic disorder is acquired, as a result of brain damage that occurred after birth.

The congenital epilepsies could be the result of the child having a gene that is responsible for the epileptic disorder; these are the genetic types of epilepsy. Alternatively, congenital epilepsy may be the result of factors that interfere with the development of the brain during gestation, resulting in brain malformations.

In acquired epileptic disorders, the damage might occur at the time of birth, for example the case of newborns that have oxygen deprivation during labor and delivery; or intracranial bleeding, as seen in some children born prematurely. Also, the brain damage may occur any time after birth. For example, epilepsy could be a complication of infections in the brain (meningitis, encephalitis), head injuries with brain damage, brain tumors, or intracranial bleeding.

Are seizures bad for children?

Presently there is no indication that short-lasting seizures will result in any brain damage. However, prolonged seizures, especially generalized tonic-clonic seizures, in some cases could result in brain damage, but this is very unusual.

Although brain damage is not likely, children can be injured at the time of the seizures. For example, in the atonic seizures there is a sudden loss of muscle power and, if this happens when the patient is standing, it is followed by a fall that might result in injuries to the face and/or mouth. Similar types of physical injuries can happen with other seizures.

For more information visit:          http://www.medworldindia.com     
                    https://www.facebook.com/medworld.india

Please scan and email your medical reports  to us at care@medworldindia.com and we shall get you a Free Medical Opinion from India’s Best Doctors.

Call Us : +91-9811058159

Mail Us : care@medworldindia.com

What are the benefits of DBS surgery? - Best Neurosurgery Hospital in India

When should one consider surgical therapy? 
 
For patients with early Parkinson's disease, levodopa (sinemet) and other antiparkinsonian medications are usually effective for maintaining a good quality of life. As the disorder progresses, however, medications can produce disabling side effects. Many patients on long-term levodopa develop troublesome dyskinesias, excessive movements that often cause the limbs and body to writhe or jump. In addition, their dose of levodopa no longer lasts as long as it once did. This may lead to "on-off fluctuations," a condition in which the ability to move changes unpredictably between a mobile ("on"), state when medication seem to work, and an immobile ("off") state in which little effect of medication is apparent and normal movement is very difficult. When patients no longer have an acceptable quality of life due to these shortcomings of medical therapy, surgical treatment should be considered. 
 
What are the different types of surgery for Parkinson's disease? 
 
There are several different types of surgery for Parkinson's disease. The first surgical procedures developed were the ablative, or brain lesioning, procedures. Examples of lesioning surgery include thalamotomy and pallidotomy. Lesioning surgery involves the precisely controlled destruction, using a heat probe, of a small region of brain tissue that is abnormally active. It produces a permanent effect on the brain. In general, it is not safe to perform lesioning on both sides of the brain. 
 
We continue to perform some lesioning surgeries for patients who desire it, although in our practice lesioning has been largely replaced by deep brain stimulation (DBS). DBS surgery involves placing a thin metal electrode (about the diameter of a piece of spaghetti) into one of several possible brain targets and attaching it to a computerized pulse generator, which is implanted under the skin in the chest (much like a heart pacemaker). All parts of the stimulator system are internal; there are no wires coming out through the skin. To achieve maximal relief of symptoms, the stimulation can be adjusted during a routine office visit by a physician or nurse using a programming computer held next to the skin over the pulse generator. Unlike lesioning, DBS does not destroy brain tissue. Instead, it reversibly alters the abnormal function of the brain tissue in the region of the stimulating electrode.

 
Many patients inquire about the "restorative" therapies, a category of procedures which includes transplantation of fetal cells or stem cells, growth factor infusion, or gene therapy. These procedures attempt to correct the basic chemical defect of Parkinson's disease by increasing the production of dopamine in the brain. In the future, restorative therapies will hopefully emerge as effective and possibly curative interventions for Parkinson's disease. Growth factor therapy for Parkinson’s disease

 
What are the possible brain targets for DBS?
 
There are now four possible target sites in the brain that may be selected for placement of stimulating electrodes: the internal segment of the globus pallidus (GPi), the subthalamic nucleus (STN), the pedunculopontine nucleus (PPN), and a subdivision of the thalamus referred to as Vim (ventro-intermediate nucleus). These structures are small clusters of nerve cells that play critical roles in the control of movement. Thalamic (Vim) stimulation is only effective for tremor, not for the other symptoms of PD. Stimulation of the globus pallidus or subthalamic nucleus, in contrast, may benefit not only tremor but also other parkinsonian symptoms such as rigidity (muscle stiffness), bradykinesia (slow movement), gait problems, and dyskinesias 

How does DBS work? 
 
The theoretical basis for DBS of the GPi or STN in PD was worked out in the late 1980's and early 1990's. In Parkinson's disease, loss of dopamine-producing cells leads to excessive and abnormally patterned activity in both the GPi and the STN. "Pacing" of these nuclei with a constant, steady-frequency electrical pulse corrects this excessive and abnormal activity. DBS does not act directly on dopamine producing cells and does not affect brain dopamine levels. Instead, it compensates for one of the major secondary effects of dopamine loss, the excessive and abnormally patterned electrical discharge in the GPi or the STN. The exact mechanism by which the constant frequency stimulation pulse affects nearby brain cells has not been determined. 
 
How is the surgery performed?
 
There are several available surgical methods. In the most common method, implantation of the brain electrode is performed with the patient awake, using only local anesthetic and occasional sedation. The basic surgical method is called stereotaxis, a method useful for approaching deep brain targets though a small skull opening. For stereotactic surgery, a rigid frame is attached to the patient's head just before surgery, after the skin is anesthetized with local anesthetic. A brain imaging study (MRI or CT) is obtained with the frame in place. The images of the brain and frame are used to calculate the position of the desired brain target and guide instruments to that target with minimal trauma to the brain. After frame placement, MRI/CT, and calculation of the target coordinates on a computer, the patient is taken to the operating room. At that point an intravenous sedative is given, a Foley catheter is placed in the bladder, the stereotactic frame is rigidly fixed to the operating table, a patch of hair on top of the head is shaved, and the scalp is washed. After giving local anesthetic to the scalp to make it completely numb, an incision is made on top of the head behind the hairline and a small opening (1.5 centimeters, about the size of a nickel) is made in the skull. At this point, all intravenous sedatives are turned off so that the patient becomes fully awake. 
 
To maximize the precision of the surgery, we employ a "brain mapping" procedure in which fine microelectrodes are used to record brain cell activity in the region of the intended target to confirm that it is correct, or to make very fine adjustments of 1 or 2 millimeters in the intended brain target if the initial target is not exactly correct. The brain mapping produces no sensation for the patients, but the patient must be calm, cooperative, and silent during the mapping or else the procedure must be stopped. The brain's electrical signals are played on an audio monitor so that the surgical team can hear the signals and assess their pattern. The electronic equipment is fairly noisy, and the members of the surgical team often discuss the signals being obtained so as to be sure to interpret them correctly. Since each person's brain is different, the time it takes for the mapping varies from about 30 minutes to up to 2 hours for each side of the brain. The neurological status of the patient (such as strength, vision, and improvement of motor function) is monitored frequently during the operation, by the surgeon or by the neurologist. 
 
When the correct target site is confirmed with the microelectrode, the permanent DBS electrode is inserted and tested for about 20 minutes. The testing does not focus on relief of parkinsonian signs but rather on unwanted stimulation-induced side effects. This is because the beneficial effects of stimulation may take hours or days to develop, whereas any unwanted effects will be present immediately. For the testing, we deliberately turn the device up to a higher intensity than is normally used, in order to deliberately produce unwanted stimulation-induced side effects (such as tingling in the arm or leg, difficulty speaking, a pulling sensation in the tongue or face, or flashing lights). The sensations produced at high intensities of stimulation during this testing are experienced as strange but not painful. We thus confirm that the stimulation intensity needed to produce such effects is higher than the intensity normally used during long-term function of the device. 
 
Once the permanent DBS electrode is inserted and tested, intravenous sedation is resumed to make the patient sleepy, the electrode is anchored to the skull with a plastic cap, and the scalp is closed with sutures. The stereotactic headframe is removed. The patient then receives a general anesthetic to be completely asleep for the placement of the pulse generator in the chest and the tunneling of the connector wire between the brain electrode and the pulse generator unit. This part of the procedure takes about 40 minutes. . 
 
 
Why must patients be awake for part of DBS surgery? 
 
Using the standard, microelectrode guided technique for DBS surgery, brain mapping is performed using microelectrodes. The brain mapping procedure is much harder to do if the patient is under a general anesthetic or strong sedative. In addition, the procedure is safer if the patient's neurological function (speech and voluntary movement) can be checked periodically during the procedure, which is only possible in an awake patient. For patients undergoing surgery in our investigational interventional MRI protocol, general anesthesia is used for the whole procedure, as the MR images take the place of electrical mapping and monitoring of neurological function. 
  
What are the benefits of DBS surgery? 
 
The major benefit of DBS surgery for PD is that it makes movement in the off-medication state more like the movement in the on-medication state. In addition, it reduces levodopa-induced dyskinesias, either by a direct suppressive effect or indirectly by allowing some reduction in medication dose. Thus, the procedure is most beneficial for Parkinson's patients who cycle between states of immobility ("off" state) and states of better mobility ("on" state). DBS smoothes out these fluctuations so that there is better function during more of the day. Any symptom that can improve with levodopa (slowness, stiffness, tremor, gait disorder) can also improve with DBS. Symptoms that do not respond at all to levodopa usually do not improve significantly with DBS. Following DBS, there may be a reduction, but not elimination, of anti-Parkinsonian medications. At present, we believe that DBS only suppresses symptoms and does not alter the underlying progression of Parkinson's disease