Sunday, August 27, 2000

Needle implanted in brain aids Parkinson's patients




By Tim Bonfield
The Cincinnati Enquirer

        A month ago, Parkinson's disease was causing Fred Dye's left arm to shake so badly he needed help to get dressed.

        His leg would seize up so intensely he couldn't work and couldn't drive. In fact, the physical pain and mental anguish of gradually losing control of his body was enough to make the 59-year-old Sharonville man consider suicide.

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        Now, however, Mr. Dye can walk without constantly relying on a cane. His hands are steady enough to tinker with bicycles and lawnmowers that need repair.

        Mr. Dye isn't cured and he isn't completely back to normal. But his life has improved dramatically, thanks to a needle-like probe permanently implanted in his brain to control his tremors.

        Doctors call it “deep brain stimulation.” The treatment, which involves a high-tech device that won FDA approval in October, has been hailed among experts as one of the few major improvements in treatment in Parkinson's disease in many years.

        On July 18, Mr. Dye became the first patient to have the device installed at Bethesda North Hospital in Montgomery — the first time the device had been implanted locally outside University Hospital.

        Mr. Dye's successful treatment increases hope for an estimated 400 to 500 other Tristate residents with severe cases of Parkinson's disease that no longer respond to medications. Doctors also say his case represents another sign that high-tech medicine can continue spreading to Cincinnati's suburbs — if the money can be found to pay for it.

        “This is as cutting edge as it gets anyplace in the country,” said Dr. Robert Schwetschenau, a neurosurgeon who installed the device. “The Bethesda Foundation has brought a very promising treatment program to the people who come to Bethesda North Hospital. But without the foundation, this program wouldn't be here.”
       

The disease
        Parkinson's disease affects about 1 million Americans and many more worldwide. Those suffering from the disease include Pope John Paul II, former heavyweight boxing champion Muhammad Ali, U.S. Attorney General Janet Reno and actor Michael J. Fox.

        Parkinson's is a neurological disorder that causes tremors, muscle rigidity, garbled speech and other motor-control problems. The disease occurs when a nerve center in a part of the brain called the thalamus begins to deteriorate. As a result, brain cells gradually stop producing dopamine, a neurotransmitter that helps control movement.

        Mr. Dye, who had worked for 29 years at Borden Inc., an ink-making company in Woodlawn, was diagnosed in 1994. The tremors along his left side eventually got so bad he couldn't run the machines anymore.

        For several years, medications that mimic dopamine have helped control Mr. Dye's symptoms. But in the past year and a half, the drugs lost their power. Mr. Dye said he heard about deep brain stimulation during a support group meeting in Kenwood.

        “A lady there told us about it. Then I talked with my wife and we talked to the doctors and we went from there,” Mr. Dye said.

        Someday, researchers hope to cure Parkinson's disease through genetic therapies or via stem cell transplants. The stem cell concept got a boost this week when the National Institutes of Health announced plans to lift a funding moratorium on research.

        But those therapies remain years away. For now, thousands of patients — mostly in Europe — already have benefited from deep brain stimulation.
       

The device
        The Activa brand device, made by Medtronic Inc., works on the brain much as a pacemaker works on a heart.

        An needle-like probe about half as thick as a coffee-stirring straw is carefully pushed deep into the brain to a spot known to control tremors.

        The probe is connected by wires running under the scalp and under the skin of the neck to a pulse generator placed under the muscles of the chest. The electric pulses then stimulate the part of the brain that controls the tremors.
       

The impact
        Counting human clinical trials and several years of approved use in Europe, the deep brain stimulation device has been implanted in about 10,000 people worldwide, according to Medtronic.

        Studies in the United States led by the University of Southern California have reported as many as 90 percent of patients achieve substantial reduction in tremors and muscle seizures after receiving the device.

        While most Parkinson's patients will continue to try medications as a first level of control, there are 400 to 500 Tristate residents with advanced cases who could benefit from this therapy, Dr. Schwet schenau said.

        In Greater Cincinnati, Bethesda North is the second hospital to offer the therapy. Dr. Jamal Taha, a neurosurgeon at University Hospital, has installed about 200 of the devices since Sept. 1997, a figure that includes many patients in clinical trials, said spokeswoman Amy Bomar.
       

The procedure
        The trickiest part of the treatment is getting the needle probe to the right place in the brain.

        The area affected by Parkinson's disease, the thalamus, lies deep inside the middle brain. If the surgeon were to miss the target by just one millimeter to the side, the probe could cause paralysis. One millimeter too deep and the patient could wind up blind.

        To achieve the precision movements needed, the Bethesda Foundation invested about $500,000 in specialized equipment.

        First, doctors mapped the least-damaging path through Mr. Dye's brain by using a series of MRI scans and custom computer mapping software. For the surgery itself, the team used an ominous-looking stereotactic head frame to keep Mr. Dye's head perfectly still.

        After drilling a small hole in Mr. Dye's skull, Dr. Schwetschenau used the computer-controlled head gear to push the probe, millimeter by millimeter into Mr. Dye's brain.

        Mr. Dye was conscious during this part of the procedure. He needed to be awake to move his limbs while the surgical team tested the device.

        The brain itself does not feel pain, Dr. Schwetschenau said. The dura tissue that surrounds the brain does feel pain, but it was numbed with a local anesthetic.

        Once the electric probe had reached the right place, the needle was fixed to a plastic plug mounted in Mr. Dye's skull. Then, while Mr. Dye was unconscious, the connecting wires were tunneled under his skin and the pulse generator was installed in his chest.

        Mr. Dye said he can move his head freely without shaking the probe and can barely feel the device.

        “I only felt some tugging when they were sewing me up. I don't even notice (the probe) is there,” Mr. Dye said.

        Doctors use a magnetic programming wand to adjust the electric pulses. Mr. Dye may need several adjustments over the next few months to get the optimal level of control.

        Even with the device not perfectly tuned, Mr. Dye's wife, Darlene, said she sees a big difference.

        “He seems a lot freer now,” she said. “He's able to act like a normal person instead of like a sick person. He still has Parkinson's but at least now he can live a better life.”

       



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