Pune’s first-of-its-kind, IMAGE GUIDED AND IMAGE VERIFIED DEEP BRAIN STIMULATION surgery performed at Sahyadri Hospitals

Pune 15th March 2022: The department of stereotactic and functional neurosurgery at Sahyadri Super Specialty Hospital Hadapsar successfully recently carried out a rare surgery of Image guided and image verified deep brain stimulation on a 58 year old suffering from Parkinsons disease.

A 58 year old gentleman suffered from Parkinson’s disease for last 8-9 years. He had uncontrolled tremors at rest, severe rigidity in all four limbs and needed hourly medications for reduce his symptoms. There was only partial relief with medication and he could not do his basic day to day activities like eating, drinking water, dressing himself, walking etc. without an assistant. He consulted senior neurologists in Pune and was advised surgical treatment for Parkinsons Disease. The patient was first seen at Nagar road Sahyadri Hospital by brain and spine specialist Dr Sachin Mahajan and senior neurologist  Dr. Nasli Icchaporia and was advised surgical treatment for Parkinson’s Disease. He was further evaluated by Dr. Manish Sabnis, Neurosurgeon at Sahyadri Speciality Hospital Hadapsar for feasibility of placement of brain pacemakers. The surgery was performed by a team consisting of neurosurgeons Dr Manish Sabnis, Dr Josna Sabnis,Anesthetist Dr Aparna Kaje, Neurologist Dr Sadiq Pathan and Neurologist Dr Aradhana Chauhan.

Giving details about the case, Neurosurgeon Dr. Manish Sabnis said that after the patient was considered eligible for Deep Brain Stimulation (DBS) he was subjected to the actual surgery which was performed keeping him awake, under local anaesthesia. DBS (Deep brain Stimulation) means implantation of 1.27mm thick electrodes in deep and delicate parts of brain and connecting it to high frequency pacemaker which modulates brain activities. Accuracy of placement of electrodes is essential as the tip lies in the mid brain and any discrepancy might result in devastating mishaps as well as failure of this therapeutical option.

Deep brain stimulation has been performed in world for last 20 years, there are few centres in india which are performing it with the help of protocol called micro electrode recording(MER). The one operated at our centre as purely performed under guidance of special CT scan and MRI images.

The protocols of obtaining high resolution images and targeting it with ultra fin accuracy was developed at Sahyadri hospital in association with The national hospital for neurology and neurosurgery Quee Square London where Dr Manish Sabnis got trained for this unique technique of PURE IMAGE BASED DBS.

Neurosurgeon Dr. Josna Sabnis said that the surgery was performed under local anesthesia (scalp block ) and through 12mm holes drilled into the skull. Throughout the placement of electrodes in brain, the patient was awake and carefully monitored. There was immediate relief from all the mentioned symptoms and patient became tremor free with complete relief from rigidity /stiffness in all four limbs. Patients activities became completely normal and his medication requirement reduced by 80%. earlier he was on hourly doses of medicines without control of symptoms but now he takes medicines only two times a day which we plan to reduce further over next few weeks.

Disease which can benefit with Deep Brain Stimulation are Parkinsons disease, essential tremors , Dystonia. It has also been used in treatment of Resistant Depression and Obsessive Compulsive Disease. The role of DBS is also being tested in case of Alzheimers disease.

Abrarali Dalal, CEO Sahyadri Hospitals said that, this achievement demonstrates that advancements in medical procedures and techniques can deliver amazing outcomes. As a leading chain of hospitals, we continue to make efforts to be at the forefront of technology to deliver best outcomes to our patients.

Supporting document

1. What is Parkinson’s disease?

Parkinson’s disease is a disease of brain characterized by tremors (shakiness of hands and legs), rigidity (stiffness in all extremities) and reduction in body movements. It is caused by timely or untimely ageing in the central portion of the brain due to lack of a chemical called dopamine which is released by brain cells called neurons. In this disease the neurons producing dopamine are lost. Due to this the patient becomes very rigid and is not able to perform routine day to day activities.

2. What are other options to treat Parkinson’s disease.?

As mentioned earlier, dopamine is available in the form of tablets. Most of the patients are first treated with medicines which either provide dopamine or medicines which prolong the action of the dopamine available in the central nervous system. Along with this normal healthy diet, proper exercises and relaxation therapies are also used to treat Parkinson’s disease.

3. What is deep brain stimulation and Who are eligible for treatment of deep brain stimulation?

Deep brain stimulation is the treatment of prescribing electrical current to the central portion of the brain through super fine electrodes implanted into it, through a pacemaker machine which is called as IPG (Implantable Pulse Generator). Stimulation of brain cells, help in improvement in functions through a complex mechanism which in turn reflects in the form of recovery from symptoms of Parkinson’s disease. This treatment has action similar to Dopamine which is specifically targeted at the required area of brain.

4. What is image guided and image verified DBS and its advantages? The part of brain where the DBS electrode is inserted, is situated in the most vital portion of midbrain. Most of the centres across world where DBS is performed use a technique called MICROELECTRODE RECORDING (MER) before inserting the electrode to verify the target. With advancement in MRI and CT scan imaging technique, in association with The National Hospital for neurology and Neurosurgery, we have developed our own protocol to use data obtained from the images to achieve super fine level precision while placing the electrodes in brain. This does not need verification with MER. Most important advantages are reduction in time of surgery (5-6 hours vs 2-3 hours), reduction in cost of microelectrodes (substantial cost reduction) and patient comfort (as patient is awake throughout the procedure). We are proud to announce that we are the first to perform this treatment in region and most probably in India as no one has done pure image guided procedure before.

5. How this treatment is performed?

Information brochure of Stereotactic Surgery, Video depicting – Leksell Frame, planning station(supercomputer) and execution of the steps while patient is awake.

6. How many days patient needs to stay in the hospital for this treatment.?

Average hospital stay of a patient is 3 days.

7. Is cost a concern for DBS? And is there any alternative for those who can’t afford it?

Yes, this is a very complex, sophisticated form of surgery. It involves placement of a machine called Deep brain stimulator or brain pacemaker in simple form. The pacemaker is produced by couple of western companies in world which carries high cost. But there is another alternative available to those who can’t afford if but want to achieve comparable results as that of DBS. The therapy is called as Lesioning. This procedure involves focussed burning of a specific area of brain which measures in millimetre in controlled environment which can bring down symptoms of Parkinson’s disease. The only difference is DBS is completely reversible and lesioning is not reversible.

8. How risky is the Deep brain stimulation procedure?

Though it’s performed with utmost precision with guidance from a supercomputer, still it remains a brain surgery. Risk of bleeding and infection is there in less than 1% cases. Since the procedure is performed by keeping the patient awake, we can pick up any major side effect at its early stage.

9. Is DBS a cure for Parkinson’s patients?

Parkinson’s disease is caused by ageing of brain cells called neuron. So, it has tendency to progress. DBS therapy is a major support to the patients of Parkinson’s Disease as far as improvement in quality of life is concerned. It prolongs the progression of the disease process, helps reducing the doses of medicines and helps in a superior quality, active healthy life to a patient. There is no cure for Parkinson’s disease.

10.What are other indications of deep brain stimulation procedure?

Along with Parkinson’s disease, DBS is proven helpful in patients suffering from Dystonia (abnormal involuntary and forceful contraction of muscles or group of muscles of body), Intentional tremors (tremors or vibrations involving hands while performing activities) as well as few psychological ailments like obsessive compulsive disorder (OCD), Resistant Depression. Its role is being tested in treatment of Alzheimer’s disease too.

11.Will you be sending this case for publishing in any peer reviewed journal?

YES. Since we have developed our own protocols of performing image guided and image verified Deep brain stimulation, we are going to write about our method of performing deep brain stimulation in national and international journals.