Deep brain stimulation surgeries, which began to be performed in the late 1980s, had an unprecedented impact on Parkinson's and similar movement disorders. Since then, no treatment method of this magnitude has emerged. Shorter surgery times, more modern electrodes, ease of stimulating the targeted point in the brain, and smaller, rechargeable batteries have greatly simplified the treatment. Today, even the settings of a deep brain stimulator can be adjusted from Türkiye for a patient who has undergone surgery and returned to America. The changes that occur in patients who meet the criteria after the surgery are astonishing. This is a report by Habertürk Health Writer Ceyda Erenoğlu.
Deep brain stimulation (DBS) surgeries, which have changed the lives of many people, especially those with Parkinson's disease, and are popularly known as "brain pacemakers," have been performed since the late 80s. The developments that have occurred since then include many changes, from the duration of the surgery to the surgical technique and the characteristics of the implanted device. And there are predictions about the future that are exciting and make people say, "I wish it would happen soon."
On April 11th, World Parkinson's Day, we met with Professor Dr. Ersoy Kocabıçak, Rector of Atlas University and a specialist in Brain and Neurosurgery, who is one of Türkiye's leading names in deep brain stimulation surgeries. We discussed the latest developments in deep brain stimulation surgeries and his predictions for the future.
Prof. Dr. Ersoy Kocabıçak, who changed the lives of his high school music teacher, a surgeon colleague, and the mothers of his friends by implanting brain pacemakers, is one of the leading surgeons in the world of brain pacemaker surgeries, with nearly 900 patients to his name. However, he says, "We should be proud not of the number of surgeries we perform, but of the results they bring."
Here are Kocabıçak's statements regarding Parkinson's disease and deep brain stimulation surgeries:
85% of Deep Brain Stimulation Surgeries are for Parkinson's Patients.
Deep brain stimulation (DBS) is defined as a surgical method used in the treatment of movement disorders such as Parkinson's disease. It involves sending low-voltage electrical impulses through electrodes implanted in the brain and yields promising results when applied to suitable patients. It is emphasized that the most important factor is the difference made by the collaborative work of an experienced team, not just a single individual. To date, over 300 people worldwide have benefited from DBS surgery. The fact that 85% of those who have undergone this surgery since 1987 are Parkinson's patients is considered the most important indicator of the surgery's contribution to these patients. Individuals whose movements are slowed, who experience muscle stiffness, tremors, and walking problems due to Parkinson's disease, are essentially given a new lease on life thanks to DBS surgery.
The number of individuals with healthy bodies but problematic brains will increase.
While significant advancements have been made in the diagnosis and treatment of some diseases today, progress in others is relatively slow. Some developments in cancer and cardiology are considered groundbreaking, but improvements in neurodegenerative diseases have not yet kept pace. It is known that the average life expectancy in developed countries is currently between 80-85 years. It is predicted that by 2050, one in two women in Central Europe will live to be 100 years old. This means an increase in individuals who are physically healthy but have some mental problems. While there haven't been major changes in medical treatments in recent years, brain-computer interfaces and surgical treatment methods have shown some progress. Although these are not paradigm-shifting advancements that will completely eradicate a disease, they are considered important.
The Most Important Development in Parkinson's Disease
Prof. Dr. Ersoy Kocabıçak says, “Deep brain stimulation (DBS) surgeries, which have been performed since the late 1980s, have caused a significant paradigm shift in the treatment of Parkinson's disease. In this disease, caused by a deficiency of dopamine produced in the brain, the passage of dopamine to the brain could not be achieved until the 1960s. The discovery of drugs that could achieve this led experts to believe for a while that 'the disease is over!' However, since Parkinson's progresses with cell loss, patients gradually began to benefit less from the medications they took. Deep brain stimulation surgeries came to the forefront precisely during this period.”
What has changed in brain stimulation?
So, what kind of developments have occurred in brain stimulation from its inception to the present day? Today, the system has become more refined, offering advantages for both physicians and patients. These include the use of more modern electrodes and the ability to stimulate specific points in the brain. This both increases the effectiveness of the treatment and reduces the likelihood of side effects. As a new development, it is noted that the large, non-rechargeable brain implants have now been replaced by smaller, rechargeable batteries.
Battery Adjustment for a Patient in America from Türkiye
It is stated that a common misconception among the public is that deep brain stimulation surgery involves implanting electrodes in the brain, not a battery. This system has three parts: electrodes implanted in the brain, a battery implanted in the chest area, and an extension cable connecting them. The system is completely closed, and the electrical level is adjusted externally using a telemetric measuring device. Professor Dr. Ersoy Kocabıçak says that recently, it has become possible to connect to the implanted batteries remotely: “Let's say our patient comes to Türkiye from the USA. When they return to the USA, we can connect to their battery remotely and make the adjustments we want. This is a very important development that has occurred in the last two or three years. Another equally important development is rechargeable batteries. Non-rechargeable batteries, due to the electricity consumption depending on the patient's needs, would run out in an average of 5-6 years (it could be shorter or longer). In this case, we had to perform a smaller surgery to replace the patient's battery. Thanks to rechargeable batteries, this is no longer necessary.”
MR-Compatible Batteries
Over time, it appears that the difficulties experienced by individuals who have undergone deep brain stimulation are becoming a thing of the past. One example is the fact that in the past, deep brain stimulators implanted in patients were not compatible with MRIs. Patients who underwent deep brain stimulation surgery could not have every MRI scan; overcoming this obstacle is considered a significant development. Ten years ago, patients who had surgery and met the appropriate criteria could only undergo lower-resolution MRIs such as 1.5 Tesla MRIs, but especially in the last 3-4 years, provided they meet certain criteria, they can now undergo higher-resolution 3 Tesla MRIs.
Other Diseases Treated
Deep brain stimulation surgery is not only performed on Parkinson's patients. Other conditions for which it is applied include essential tremor (involuntary shaking in certain areas of the body), dystonia (involuntary muscle contractions), Tourette Syndrome (repetitive movements and tics), and in recent years, psychiatric disorders such as obsessive-compulsive disorder (OCD), also known as obsession disorder, and resistant depression.
Professor Dr. Ersoy Kocabıçak, stating that successful results are obtained in dystonia and tremor diseases as well as in Parkinson's disease, says; “I must say that it is not routinely used in the other diseases I mentioned. This is a surgery that should be performed on selected patients,” and continues; “In recent years, surgeries performed on epilepsy patients have also yielded encouraging results. Although its application is not widespread in Türkiye, it has almost become routine in Europe and America in suitable cases. Apart from this, it is also applied in case-level cases of anorexia nervosa, autism, post-traumatic brain injury, and addiction worldwide. Although very important studies conducted by a Canadian group regarding Alzheimer's have not yet yielded the expected results, some things may change in the future regarding Alzheimer's.”
Parkinson's Disease: Well-Known and Little-Known Symptoms
Parkinson's disease, a chronic and progressive illness, is defined as a "dopamine deficiency" in a region of the brain. Dopamine is a chemical that provides fluidity in our bodies, allowing for easy movement. A decrease in this substance leads to certain symptoms. Lack of fluidity causes slowness of movement, tremors, joint stiffness, and gait disturbances. These are seen as motor symptoms. There are also non-motor symptoms, which appear at the onset of the disease and include problems such as decreased sense of smell, constipation, sleep disturbances, and a predisposition to depression. It's important to know that not every symptom is indicative of this disease.
Is there a connection to the second brain?
Since Parkinson's disease is diagnosed by neurologists, it is recommended to consult a neurologist if some of these symptoms are present together. Going to a neurosurgeon for diagnosis is considered a common mistake. Parkinson's disease particularly appears in people aged 60 and over. Affecting one in 100 people, the disease is increasingly seen after the age of 65. While the incidence of "Young Parkinson's," where genetic predisposition is prominent, has increased in recent years, studies suggest that environmental factors and lifestyle also play a role. Studies highlighting a possible link between a disrupted gut microbiota, often referred to as the "second brain," and Parkinson's disease are particularly noteworthy. This underscores the importance of healthy and regular nutrition, with experts especially recommending a Mediterranean-type diet.
Symptoms Requiring Surgery
Patients diagnosed with Parkinson's disease initially receive medication prescribed by a neurologist. If the medications they use in the first few years become less effective or their duration of action shortens (for example, a medication that previously lasted 4-5 hours may now last only 30 minutes), they need to take more medication. This requires careful attention to potential side effects (involuntary movements, etc.). Furthermore, an increase in the frequency of immobile periods indicates that surgery is due.
Prof. Dr. Ersoy Kocabıçak stated: “This surgery should be considered and accepted as a patient's right in suitable patients. At this point, we need physicians who are experienced in this field and dedicated to a specific area. Although we have many valuable neurologists specializing in movement disorders in our country, patients often turn to neurologists with less awareness of the subject when they cannot reach them initially. Due to the importance of this issue, we are not sitting idle; we aim to raise awareness through training seminars, congresses, and conferences, and to ensure that patients who would benefit from deep brain stimulation reach us in a timely manner. On this occasion, I would like to say that I consider the presence of neurologists who encourage us to perform this surgery even more than we do to be very important.”
Can a deep brain stimulator be implanted in a patient who does not benefit from medication?
The question of whether deep brain stimulation can be performed on patients who do not benefit from medication is reportedly controversial. Professor Dr. Ersoy Kocabıçak states that patients who do not benefit at all from medication should be informed that the probability of them benefiting from surgery is negligible. He continues, “Although there are publications claiming that patients may benefit from surgery even if they do not benefit from medication, it should be noted that these are at the case level. In our clinic, we perform deep brain stimulation surgery on patients who benefit from medication even for 15 minutes, but we do not perform this surgery on those who do not benefit, and we do not recommend it.”
Situations Requiring a Red Line
There are important considerations during the decision-making process for deep brain stimulation surgery, the surgical procedure itself, and the post-operative period. Deep brain stimulation surgery can sometimes worsen cognitive impairment. Therefore, this surgery should not be performed on individuals with dementia symptoms. It is also stated that the surgery is not performed on those who have attempted suicide or have resistant depression (the fact that deep brain stimulation surgery is performed on some depressed individuals but not others is due to the targeting of different areas of the brain). In these cases, considered a critical threshold, surgery is only performed after the individual's underlying problems have been resolved.
The Two Most Important Criteria
It is crucial that the correct deep brain stimulation surgery is performed in the right center with meticulous surgical techniques. The most important criteria are patient selection and the precise execution of the surgery. While teamwork and post-operative planning are also considered crucial, it is emphasized that these two criteria are paramount.
One in five patients undergoes surgery.
The team that decides on deep brain stimulation surgery includes neurologists specializing in movement disorders, neurosurgeons, psychiatrists, psychologists, speech therapists, physiotherapists, specially trained nurses, and dieticians. The significant difference in success rates between deep brain stimulation surgery performed in a single center and surgery without a multidisciplinary approach is highlighted. It is stated that the solution goes far beyond simply placing two electrodes in the brain, and achieving results with a non-multidisciplinary approach is impossible.
“We frequently discuss this issue in our own meetings and at the congresses we organize,” says Prof. Dr. Ersoy Kocabıçak, adding that the negative consequences of this treatment can even cause people who could benefit from it to abandon the surgery. Stating that half of the success of these surgeries depends on the surgeon's skill and the other half on each individual in the team fulfilling their duties flawlessly, Kocabıçak says, “We have been organizing congresses for years to raise awareness about this. We established the 'Deep Brain Stimulation Association,' which I also chair, for this purpose. Furthermore, I am both a founding member and a board member of the 'International Deep Brain Stimulation Association,' which we established together with the most respected scientists in this field from other countries. Our goal should be to bring all disciplines together, speak the same language, and act with common sense.”
Features of the Surgery That Was Reduced from 8 Hours to 2 Hours
During deep brain stimulation surgery, patients are usually awake. They stay in the hospital for one or two days before the surgery and about 5 days after. The stitches are removed on the 10th day. After being discharged from the hospital, patients are called for follow-up appointments three times within 3 months. Although the results of the surgery are visible from the first day, the patient reaches their best condition after 3 months. Follow-up appointments continue in the period after that. Some patients' symptoms may return years later. At this point, comparisons made over many years between patients who had surgery and those who did not show that those who had surgery have a much higher quality of life than those who did not. The return of symptoms over the years is due to the progressive nature of the disease. It is stated that the goal here is not to stop the disease but to slow its progression. The fact that deep brain stimulation surgery, which took 8 hours when it was first applied, has been reduced to 2-2.5 hours today is also among the positive aspects.
Heartwarming Patient Stories
Although their numbers are very small, it is stated that deep brain stimulation surgery is also performed on patients with Multiple Sclerosis (MS). Professor Dr. Ersoy Kocabıçak, who says there are 7-8 such cases in Türkiye and that he is one of the most frequent performers of this surgery, states: “We had a young patient diagnosed with MS who had a serious tremor problem. While we were performing the surgery and talking to him, he joyfully said, 'Now I can peel my own fruit, cook my own food, and eat it myself,' and started to cry. This situation made the entire team, including myself, cry in the operating room. Recently, I operated on a 19-year-old with Tourette Syndrome (tic disorder). He was so happy with the result that he said, 'Professor, if I ever have a child, I will name it after you.' These aspects of our profession make us very happy.”
Expected Developments
Although deep brain stimulation surgeries are very successful, there are shortcomings that need to be addressed. Considering the speed and advancements in technology today, it is stated that these can be further developed. Professor Dr. Ersoy Kocabıçak, who believes that the best surgery has yet to be achieved, explains his belief as follows: “Medicine is advancing very rapidly. We are currently only applying and discussing electrically based treatments. However, light-based and nanoparticle-based treatments are also coming. We have expectations such as smaller batteries and thinner electrodes. We foresee that the connection system we call an extension cord will be eliminated, and Bluetooth connections will increase significantly. Nevertheless, the day these expectations will be realized is not today. Although our greatest weapon at the moment is the treatments we apply, we believe that what we envision will come true.”
The Surgery That Provides the Highest Sense of Satisfaction
Among all neurosurgical procedures, deep brain stimulation is considered one of the most rewarding. It is stated that the immediate relief experienced by patients with severe tremors, inability to eat, button their shirts, and intense tics, and the gift of a new life given to them, is priceless. "Six or seven years ago, after performing surgery on a young girl who couldn't control her swearing due to tics, I heard her say, 'Now I can sit quietly in a library and study,'" says Prof. Dr. Ersoy Kocabıçak, continuing, "The happiness of touching the lives of people with such difficulties is indescribable. Speaking specifically about Parkinson's, facilitating the change in the lives of people who cannot perform self-care is a very special feeling."
April 11th is Parkinson's Awareness Day.
April 11th, World Parkinson's Day, is a day aimed at raising awareness about the disease in Türkiye and around the world. To mark this special day, a panel highlighting the importance of a multidisciplinary approach was held at the Neuromodulation Center of Atlas University Hospital. On the same day, patients and their relatives came together at the Parkinson's Patient School, where they received comprehensive information. Beyond contributing to awareness among patients and their families, the Parkinson's School also demonstrated the importance of personalized support by fostering a sense of closeness and connection among patients who have experienced the same problem.
