Deep Brain Stimulation for Parkinson’s disease: A case report

Anandhi Sathyakumar1*, Roselin2, Stella Towncent3, P. Jose Lincy4

1Nursing Director, Kauvery Hospital, Chennai, Tamilnadu, India

2Deputy Nursing Superintendent, Kauvery Hospital, Chennai, Tamilnadu, India

3,4Nurse Educator, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: M: +91-9790861662; Email ID:[email protected]

Introduction

Parkinson’s disease is a disabling chronic neurodegenerative disorder which was clinically characterized by akinesia, tremor, rigidity, and postural instability caused by dopaminergic neuron degeneration of the substantia nigra. Young-onset Parkinson’s disease is a unique subgroup among patients with Parkinson’s disease. Deep Brain Stimulation was first used in 1986 to treat the medically refractory tremor in Parkinson’s disease. During the last two decades deep brain stimulation has been established as a highly effective therapy for advanced Parkinson’s disease, on the Indian population by Behari et al., the risk factors included that of male gender who had higher incidence (1:3.96) similar to that reported in other countries.

Background

Deep Brain Stimulation effects may decrease with Parkinson’s disease progression. A 2022 Parkinson’s Foundation-backed study reveals that nearly 90,000 people are diagnosed with Parkinson’s disease every year in the U.S. This represents a steep 50% increase from the previously estimated rate of 60,000 diagnoses annually. According to the Parkinson’s Foundation Parkinson’s Prevalence Project 1.2 million people in the U.S. will be living with Parkinson’s by 2030. Rural population had a higher prevalence compared to the urban population. The prevalence rate in Europe is 1.8 per 100 in population above 65 years. As the prevalence of PD in non-white population is lower, the normal human brains from India and United Kingdom were compared, to determine the cause. Anglo-Indians, who had admixed ethnicity with Indian population had nearly five times lesser prevalence of PD compared to general Indian population. In summary, there may be several other factors causing the difference in prevalence in varied populations and this need to be explored. Patients with PD, because of their disability, can have poor QOL-physical, psychological, and social. Several studies have shown significant decrease in QOL in these patients. The important clinical variables found to cause lower QOL in India were depression, disease severity, disability in off periods, dyskinesia, postural instability, gait disturbances, and cognitive dysfunction. The QOL was also found to be influenced by disease stage, severity, duration, and financial security.

Case presentation

A 36 years aged male patient was admitted with the complaints of dyskinesia, non-predictable rigidity, slowness while still on medication and dyslipidemia for 5 years. He was on Tab. Syndopa plus for 5 years. The patient had undergone an appendectomy 20 years back. Levodopa challenge test and UPDRS were done. Cardiologic fitness and a psychologist’s opinion were taken Discussion was done with neuro surgeon & three neurologists. A

A surgical procedure Deep Brain Stimulation was planned and done. Postoperatively patient was under treatment of T. Rosuvas (Statin), T. Syndopa (Anti-Parkinson agent), Inj. Cefuroxime (antibiotics) and Inj. Paracetamol (analgesics). GCS was intermittently noted.

During discharge, patient was advised to continue Statin and Anti Parkinson drug. Patient condition improved and was clinically stable.

On clinical assessment

TemperaturePulseRespirationBlood pressureSPO2GCS
97.6°F78b/min20 b/min134/86 mm/Hg97%13

Investigation reports

DateInvestigationReport
14/9/2024Haemoglobin13.9 g/dl
14/9/2024WBC7.2410^3/muL
14/9/2024Platelet count285 10^3/mu
14/9/2024PT9.7 sec
14/9/2024INR0.84 ratio
14/9/2024PTT26.1sec
14/9/2024Blood groupB positive
14/9/2024Total Bilirubin0.30 mg /dL
14/9/2024SGOT18.1 U/L
14/9/2024SGPT13.1 U/L
14/9/2024Alkaline phosphatase97.0 U/L
14/9/2024Gamma Glutamyl Transferase21.9 U/L
14/9/2024Urea30.8 mg/dL
14/9/2024Creatinine0.72 mg/dL
14/9/2024Uric acid6.24 mg/dL
14/9/2024ElectrolytesAll parameters are in a normal range
14/9/2024Tri iodothyronine107.85 ng/dL
14/9/2024Total Thyroxine8.33 Mug/d
14/9/2024Levodopa challenge test and UPDRSMotor score >50% (Improved)

Drug chart

Empirical treatment
S. NoDrugsDoseFrequency
1T. Syndopa Plus100/25 mgQID
2T. Rosuvas10 mgOD
3Inj. Para1 gmTDS
4Inj. Pan40 mgTDS
5Inj. Cefuroxime1.5 gBD
Follow Up treatment
1T. Syndopa plus100/25 mgTDS
2T. Rosuvas10 mgOD
3T. Acton OR1 gmBD

Nursing care

  • Hygiene: Encouraged and helped the patient to maintain oral and personal hygiene.
  • Nutrition: Maintained nutrition during NPO by continuous IV fluid administration. Once the patient tolerated with oral intake, started the normal feed.
  • Activities of daily living: Trained and ensured the patient to carry out his daily living activities, in order to maintain an independent self-care activity and needs.
  • Exercise: Assessed and promoted the out of bed mobilization after the surgery and monitored patient during the self-mobilization. Explained the risk for complications associated with mobilization after DBS explained the patient to call for help and not to attempt any activities by himself alone at home.
  • Infection risk: Sterile surgical site dressing was done. Ensured the patient to maintain sterile dressing at home after discharge to prevent the risk of surgical site infection.
  • Follow up: Described the action, frequency and dosage of medication with side effects prescribed during discharge. Ensured the patient to go for regular follow up and not to discontinue any medication without Doctor’s prescription.

Discussion

According to the National Parkinson foundation, DBS produces marked clinical benefits when optimized. A 80% of patients can be good responders who gradually show improvement after DBS.

Trans magnetic stimulation is an important tool used to assess the central motor circuitry and has been used extensively to study the pathophysiology of PD, In India, there have been a few studies of TMS on PD patients at SCTIMST and AIIMS. Bhatia et al., studied about threshold intensity (TI) in PD patients. There are a few centres in India which offer surgical treatment for PD and consequently there are limited studies on surgical treatment of PD from India.

There was evaluation of long-term effects of sub thalamic nucleus (STN) stimulation in 45 PD patients carried out over 5 years by Kishore et al.

Naskar et al., studied the effect of deep brain stimulation (DBS) on long latency event-related potentials, which showed an increased N100 latency, reflecting the worsening of orientation response with STN stimulation, but there was no change in P300.

Physical therapy, which is non-invasive, is an essential part of treatment for PD. Srikumar et al., from AIIMS studied 28 patients of PD undergoing pharmacological therapy. They found that a systematic program of exercises improves the UPDRS scores (35%), activities of daily living (25%), and gait (30%).

Conclusion

Levodopa has been the mainstay and the most efficient medical treatment for Parkinson’s disease. DBS was found to be effective and safe for treating motor symptoms associated with advanced stages of the disease. Patients need to undergo a comprehensive evaluation before surgery by a team of at least a specialized movement disorders neurologist and neurosurgeon.

As of conclusion, the patient prognosis was good and discharged within 2 days without any complications. During the discharge the patient was mobilizing out of bed, carried out his own activity and tremors comparatively subsided.

References

  • A S.J. Groiss, L. Wojtecki & et al., Deep Brain Stimulation, national Library of Medicine (National Center for Bio technology Information), Nov 2009, Page No: 20-28.
  • Hariz M, Blomstedt P, Deep brain stimulation for Parkinsons Disease, Intern Med Journal, 2022, Page No: 764-778.
  • Fan S, Liu D & et al. Differential effects of subthalamic nucleus and globus pallidus internus deep brain stimulaion on motor subtypes in Parkinsons Disease, World Neurosurg Jounal, Published in April 2022, Page No: 84.
  • Krauss JK, Fernandes FW, et al. Svennilsons publication on pallidotomy for parkinsonism in 1960, published in Pubmed, September, 2021, Page No: 173.
  • Pratibha Surathi, Ketan Jhunjhunwala & et al. Research in Parkinson’s disease in India: A review, Annals of indian Academy of Neurology, published on Jan 2016, Page No: 9-23.

Ms. Anandhi Sathiyakumar
Nursing Director

Ms. Roseline
Deputy Nursing Superintendent

Ms. Stella Towncent
Clinical Nurse Educator

Ms. P. Jose Lincy
Clinical Nurse Educator

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