EP 41. Deep brain stimulation for movement disorders in Kazakhstan

Abstract

Introduction Movement disorders are very complicated diseases to treat. Sometimes medical treatment is not successful or results in unpleasant complications. There is a neurosurgical treatment for movement disorders, which is advanced and very effective in well selected cases. The DBS surgery program in Kazakhstan started in 2013. Materials and methods 130 patients with movement disorders were operated on in the National center for neurosurgery (Kazakhstan) in the period 2013–2015 including 117 PD patients, 10 dystonia cases, 1 Tourette syndrome, 1 essential tremor and 1 neuropathic pain. There were 58 male and 72 female. The average age of the patients was 51 y.o. STN was a target in 116 cases, GPi in 12, VIM – 1 and ventroposterolateral nucleus of the sensory thalamus in 1 case. Follow up of the 73 patients was more then 1 year. We used international selection criteria for DBS for PD. Their clinical assessment was established by using UPDRS. The average duration of disease was 10 years. Severe fluctuations and dyskinesia were present in 75% of cases. Focal dystonia (torticollis) was a major indication for GPi DBS. For implantation, we used the multipurpose stereotactic frame by Electa (Sweden) and SurgiPlan software by Elekta (Sweden). We implanted the DBS therapy Activa PC system from Medtronic (USA, Minneapolis), which consisted of two leads, extension cables and an IPG. Most of the cases (90%) were implanted using microelectroderecording using the LeadPoint® Micro Electrode Recording (MER) system. Results Excellent improvement of motor functions (more than 50% by UPDRS) in PD patients increased from 65% in 2013 and 71% in 2014 to 92% in 2015. Postural instability, gait problems and autonomic symptoms were less regressed. We decreased the dosage of dopaminergic drugs for 30–50% and thereafter the drug induced dyskinesia regressed in all cases. Moreover in 6 cases we postponed medication completely. DBS for dystonia was dramatically effective in cases with cervical dystonia and less successful in secondary dystonia cases. The Tourette patient became significantly better by the Yale Global Tic Severity Scale but after cancelling the drugs there was a sudden deterioration. We are continuing to follow up him. The essential tremor case became better but not completely. We had complications in 12 cases: 1 symptomatic bleeding with hemiparesis, 2 asymptomatic bleeding with successful reimplantations, 7 infection and 2 tromboembolism (1 fatal). The patient who bled was implanted again after intensive care and rehabilitation. Two infected cases were reimplanted in 6 months. Getting more experience using special protocols and standards based on evidence medicine the rate of complications decreased year after year. Conclusion Deep brain stimulation is an effective treatment of PD and can decrease main symptoms of the disease: rigidity, tremor and bradykinesia and sometimes postural instability and gait problems. Dystonia and essential tremor are the real indication for DBS. More indications should be investigated using stereotactic neurosurgery. The right patient selection is the key for good results in this procedure. There is a DBS program in Kazakhstan in the National Center for neurosurgery.