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Dr. Krishi

MPTh/MPT

Neurologist, Hyderabad

15 Years Experience  ·  200 at clinic
Dr. Krishi MPTh/MPT Neurologist, Hyderabad
15 Years Experience  ·  200 at clinic
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I want all my patients to be informed and knowledgeable about their health care, from treatment plans and services, to insurance coverage....more
I want all my patients to be informed and knowledgeable about their health care, from treatment plans and services, to insurance coverage.
More about Dr. Krishi
Dr. Krishi is a popular Neurologist in Nizampet, Hyderabad. Doctor has been a practicing Neurologist for 15 years. Doctor is a MPTh/MPT . Doctor is currently associated with Varsha Physiotherapy Clinic in Nizampet, Hyderabad. You can book an instant appointment online with Dr. Krishi on Lybrate.com.

Lybrate.com has a nexus of the most experienced Neurologists in India. You will find Neurologists with more than 44 years of experience on Lybrate.com. Find the best Neurologists online in Hyderabad. View the profile of medical specialists and their reviews from other patients to make an informed decision.

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Education
MPTh/MPT - MNR Medical College, Sangareddy, - 2002
Languages spoken
English

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Varsha Physiotherapy Clinic

Ground Floor, Teja Nilayam, Nizampet. Landmark: Besides Vijetha Super Market, HyderabadHyderabad Get Directions
200 at clinic
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My brother has cervical spondolysis problem and has feeling of numbness in hand and a bit of swelling on back side.

BHMS
Homeopath, Faridabad
My brother has cervical spondolysis problem and has feeling of numbness in hand and a bit of swelling on back side.
Hi. Sleeping on your back without a pillow to encourage the natural curves along the spine to align properly. Also sleeping on your side with a pillow that is the size of the gap between your shoulder and head to release the strain on the neck. Using too many pillows is not recommended. Regular exercise lubricates the disks of the spine and helps to combat degeneration of the disks. Exercise can help keep your body strong and supple as you age. High-impact exercises such as running should be avoided if you are experiencing any neck pain because the shock of impact can worsen your condition. Light, low-impact exercises such as walking, swimming or aqua aerobics help to support the body. Using a routine of neck stretches and yoga exercises will maintain flexibility and range of motion in the neck and cervical spine. Sit up tall with good posture. Roll the shoulders up and back. Inhale and lift the head up toward the sky. Exhale and drop the head toward the chest. Repeat this movement with your breath 10 to 15 times. Bring the head back to center and drop the right ear toward the right shoulder. Repeat on the left side and continue for 10 to 15 repetitions. Roll the head in circles to the right and then to the left. Drop the right ear toward the right shoulder and press the right hand gently into the left side of the forehead to increase the stretch. Repeat on the other side. Yoga (better do it under supervision and guidance by a qualified yoga-instructor first and do it alone later): Certain yoga postures such as Cobra and Bridge pose help to strengthen and stretch the muscles of the neck. Perform Bridge pose lying on your back with the knees bent and feet flat on the floor. Press the feet into the floor and lift the hips up toward the sky. Clasp the hands underneath the body and straighten the arms. For Cobra pose, start on your stomach. Bring your hands to either side of your chest. Press the hands into the floor and roll the shoulders back. Lift the upper body off of the floor and press the tops of the feet into the floor. Elongate the neck and move the tips of the ears back toward the shoulders.
1 person found this helpful
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I have hand shivering from childhood. I am really ashamed before other. Can you please tell me how it can stopped. Shivering is more if someone watches when I am doing some sensitive thing.

DM - Neurology
Neurologist,
You probably have essential tremor; this should be confirmed visually by a neurologist; once that is done, it can be treated with drugs in appropriate doses. Et cannot be cured, but the tremor can be improved while on medication.
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I have headache problem from few years But I don't know is it migraine How should I do come to know that I have migraine?

MBBS, cc USG
General Physician, Gurgaon
Hello, i am giving you common symptom of migraine Headache eye pain. (most commonly one-sided pain; less frequently both sides of the head are affected) pain located near the eye on affected side. pain that worsens with exertion or physical activity. Nausea/ Vomiting sensitivity to light and/or sound. consult again for further management
1 person found this helpful
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I have persistent numbness in both hand and feet since 5 days. I have done my full body checkup. All report is normal. Bp is 140/90. Dr. prescribe me trineurosol hp inj. Afer taking 3 inh no improvement is seen. What should I do.

Diploma in Obstetrics & Gynaecology, MBBS
General Physician, Delhi
I have persistent numbness in both hand and feet since 5 days. I have done my full body checkup. All report is normal...
You have borderline high bp, reduce salt but I am not suggesting a salt free food. Avoid tinned foods as salt is a preservative. Avoid other packed foods also like chips, namkeem, street foods. Use minimum oils for cooking. Eat lots of seasonal vegetables and fruits. Reduce stress by exercise and yoga and meditation. Take a tablet of safe betablocker like metoprolol 25 mg twice daily. Get back here with progress reports only after observations, after 2 weeks. Get back here with reports. You will get more guidance from any of us here on the forum.
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I am suffering from migraine, wat are the diagnostics and medicines I have to use.

Certified Diabetes Educator, Registered Dietitian (RD), PGDD, Bachelor of Unani Medicine and Surgery (B.U.M.S), General Physician
Dietitian/Nutritionist, Mumbai
migrane can be managed with lifestyle changes and medications, try muscle relaxation exercises. Relaxation may help ease the pain of a migraine headache. Get enough sleep, but don't oversleep. Get an adequate amount of sleep each night. It's best to go to bed and wake up at regular times, as well. Rest and relax. If possible, rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp. It is very important keep a headache diary. Continue keeping your headache diary even after you see doctor. It will help you learn more about what triggers your migraines and what treatment is most effective. A dose of riboflavin in appropriate dose as prescribed by me, also may prevent migraines or reduce the frequency of headaches. Coenzyme q10 supplements may decrease the frequency of migraines, magnesium supplements may also be used to treat migraines do reply back for medication prescriptions. Being also a general physician and registered dietitian, I prescribe both evidence based herbal as well as allopathic medicines complementing with dietary guidelines and home remedies carefully personalized for each individual patient.
9 people found this helpful
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My 17 year old daughter have cerebral palsy. She is quaderiplebgic. I have heard about Dr. Bernard brucker. Biofeedback therapy. Can this therapy will help her in any way?

M.P.T. (Neuro), BPTh/BPT
Physiotherapist, Lucknow
Yes it is helpful but other treatments are aldo available like ndt, botox injection. And stem cell therapy.
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I am 65 years old I am suffering from varicose veins in left foot also neuropathy for that I taken pregab75 one daily night, still i am suffering burning sensation in both feet i am not diabetic only having bp for that I am taking lose-h & ecosprin gold 20 in morning for burning sensation what treatment I should take?

MD-Ayurveda, Basic Life Support (B.L.S), Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Ahmednagar
I am 65 years old I am suffering from varicose veins in left foot also neuropathy for that I taken pregab75 one daily...
For burning sensation n neuropathy our herbal medicine works very effectively; as its age related problem. Due to old age you r also suffering from blood pressure; our herbs also helps to keep your vessels clean to avoid blockage in vessels through which you will stay away from paralysis or heart attack; so you may go for our herbs. Varicose veins cannot be treated effectively by any pathy so don't try to treat them as it may harm your body. Just do pranayam n few yogasanas if possible; consult with me for more details.
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I'm suffering from migraine and I have no medicine intake in migraine. My ques is migraine is dangerous in my future.

MD - Homeopathy, BHMS
Homeopath, Ahmedabad
Dear Lybrate user, Migraine is make your life miserable it can cause you symptoms but it is not fatal. Here is the some information for you hope it would be helpful. Causes of headaches may include fatigue, sleep deprivation, stress, the effects of medications, the effects of recreational drugs, viral infections, common colds, head injury, rapid ingestion of a very cold food or beverages, and dental or sinus issues. This can trigger your headache: foods : spices, wine , chocolate, citrus • food additives • sleep : both too much and too little • stress : mainly offset Home remedies: • Stay Hydrated • Mix equal parts of ginger juice and lemon juice. Consume it once or twice a day. • Menthol and menthone are the primary components of mint which are very effective in alleviating headaches. • Peppermint contains menthol that helps open up clogged blood vessels that cause headaches. It also has calming and soothing effects. • Basil works as a muscle relaxant, making it a helpful treatment for mild headaches caused by tense muscles. Plus, it has calming and analgesic effects. • Simply smelling the soothing scent of lavender essential oil can be of great help in relieving tension headaches. Research suggests that it can also help improve migraine symptoms. • The cold from ice helps reduce inflammation that contributes to headaches. Plus, it has a numbing effect on the pain. • Simply massage your forehead and temples with a few drops of rosemary oil mixed in a tablespoon of carrier oil. • Crush a few cloves gently and put them in a sachet or a clean handkerchief. Inhale the smell of the crushed cloves whenever you have a headache until you get some relief from the pain. • Simply eat an apple with some salt. • Accupuncture: Press and massage the fleshy area between the thumb and index finger, at the highest spot of the muscle when both the thumb and finger are brought close together. Do this for one or two minutes and then repeat on the other hand. Exercise Regular exercise can reduce the frequency and intensity of headaches and migraines. When one exercises, the body releases endorphins, which are the body’s natural painkillers. Exercise reduces stress and helps individuals to sleep at night. Stress and inadequate sleep are two migraine triggers. Homeopathic treatment In order to prescribe a homeopathic remedy, it is crucial to discover what is unique about the way an individual experiences a headache. For example, all migraine sufferers may experience nausea, but a particular individual may feel thirsty for cold drinks with the headache. Thirst for cold drinks is the characteristic symptom that sets one migraine sufferer apart from others. There are hundreds of possible remedies for the treatment of headaches, so the key is finding which homeopathic remedy most closely matches your symptoms. Do not allow Headache to make your life miserable. Switch over to the homeopathic treatments and enjoy a stress free life. Wish to know more about the effective homeopathic treatment? We are just a click away
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Epilepsy and Its Homeopathic Management!

BHMS
Homeopath, Delhi
Epilepsy and Its Homeopathic Management!

Epilepsy is a disease that affects the brain's nerve cells and triggers the release of abnormal electrical signals. This can cause temporary malfunctioning of the other brain cells and result in sudden loss of consciousness. Epilepsy can affect both children and adults.

Epilepsy can be treated in a number of ways. One of the most preferred forms of treatment is homeopathy. Homeopathy addresses both the physical symptoms of the disease and the underlying factors triggering it. Another big advantage of homeopathic treatment is that it has negligible side effects.

A few homeopathic remedies that can be used to treat epilepsy are:

  • Cicuta: Cicuta is very effective when used to treat cases of epilepsy where convulsions are marked by violent, body distortions. This can include the horrific backward bending of the spine (learn about the exercises for spine). These convulsions also make the person's face turn blue and trigger a locked jaw. This can also be used to effectively treat epilepsy cases triggered by head injuries and worms.
  • Artemisia Vulgaris: This is used to often treat cases of Petit Mal Epilepsy which are characterized by staring into space, leaning forwards or backwards and stopping a sentence abruptly. It also addresses fear that triggers epileptic attacks.
  • Stramonium: Convulsions triggered by exposure to bright lights or shiny objects can be treated with this homeopathic remedy. In such cases, the patient may not lose consciousness but experiences jerks in the muscles of the upper body.
  • Cuprum Met: This homeopathic remedy is used to treat seizures that are preceded by experiencing an aura in the knees (know more about the Causes and Symptoms of Knee Pain). Other symptoms that characterize this sort of an epileptic attack are spasms that begin in the fingers and toes and gradually spread to the rest of the body and jerking of muscles. This can also be used to treat convulsions that accompany menstruation and follow the delivery of a baby.
  • Bufo Rana: Not all epileptic attacks occur you are awake. Attacks that occur in your sleep can be treated with bufo rana. Such epileptic attacks are accompanied by experiencing an aura in the genital regions. This is especially helpful for women who experience seizures during menstruation.
  • Hyoscyamus: Some epileptic fits are followed by a deep sleep. This type of epileptic attacks can be treated with Hyoscyamus. Other symptoms addresses by this homeopathic medicine are fidgeting with bed clothes, fidgeting with fingers and muscular twitching.

These homeopathic remedies can be taken on their own or in combination with other medicines.

5521 people found this helpful

My blood pressure normally has been 130 /90 From last 15 days it has come down to 115 /65. What could be cause of the same. Remedy I suffer from sleep apnea I also take.

Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Navi Mumbai
My blood pressure normally has been 130 /90 From last 15 days it has come down to 115 /65.
What could be cause of the...
Take following remedies 1. Triphala kadha 4 tsp before lunch and dinner 2. Amala juice 4 tsp + 2tsp sugar + 2tsp honey in the morning empty stomach 3. Have 1 cup pomegranate juice at evening 4.1cup milk+ 1 tsp ashwagandha powder after dinner before sleep.
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Parkinson s Disease

MBBS, DNB, Fellowship in Neurosurgery
Neurosurgeon, Kolkata
Parkinson s Disease

Deep brain stimulation in Parkinson’s disease

Abstract: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson’s disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients.

Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be discussed.

Key words: deep brain stimulation (DBS); Parkinson’s disease(PD),  stereotaxis

Introduction

Parkinson's disease is a slowly progressive, neurodegenerative disease characterized by tremor, rigidity, bradykinesia and postural instability. It is the most common movement disorder in middle or late life with a prevalence of about 0.3% of the general population, rising to 1% in people over 60 years of age. Approximately 130 000 people suffer from it in the UK and it presents an increasing burden in our ageing population. Pathological findings in Parkinson's disease demonstrate greatly diminished neuromelanin pigmented neurons in the substantia nigra of the basal ganglia with associated gliosis, and Lewy bodies present in many remaining neurons.

James Parkinson, in his original 1817 Essay on The Shaking Palsy, gave an account of six patients in which he noted signs of tremor, festinating gait and flexed posture.  Nearly two centuries from Parkinson's observations, and almost four decades after Cotzias' dramatic demonstration of levodopa's efficacy, the limitations and complications of levodopa treatment for Parkinson's disease have become well documented Five years after initiation of therapy, a majority of patients develop medication related motor complications, namely levodopa induced dyskinesias (LID) and motor fluctuations. Deep brain stimulation (DBS) has been developed primarily to address these treatment related motor complications and therapeutic failures.

Pathophysiology of PD

The loss of dopaminergic neurons in the substantia nigra, the main functional characteristic of PD, affects the circuit described above and leads to the cardinal motor symptoms of PD. While the exact mechanism of this process is unknown, animal research as well as human recordings have provided functional and biochemical evidence that bradykinesia in PD results from excessive activity in the STN and the GPi. This leads to an exaggerated beta (10-30 Hz) synchronization within and between structures in the basal ganglia circuitry  that could also contribute to rigidity and akinesia.

The pathophysiology of rest tremor in PD is less clear and probably more complicated. This symptom most likely results from a dysfunction of both the striato-pallidal-thalamocortical and the cerebellodentato-thalamocortical circuits, with hyperactivity and hypersynchronization between central oscillators.

Possible mechanism of action of DBS

DBS acts through delivering an electrical current in a specific target area of the brain. This current can be modulated through modification of voltage, frequency and duration of each electrical pulse delivered. The delivered energy creates an electrical field of variable size and shape according to the parameters used for stimulation. Although initially believed to stimulate the target, thus the name of the whole process, it seems that

DBS actually excites the neuronal fibers, but inhibits the neural cells. In fact, GPi DBS decreases the GPi mean firing rate back to a normal range in animal models as well as PD patients, and high frequency DBS has a similar effect as dopamine replacement therapies, and promotes faster (about 70 Hz) nonhypersynchronous activity in the basal ganglia, correlated with clinical improvement. This might be achieved through stimulation of bypassing inhibitory pathways, synaptic inhibition, depolarizing blockade, synaptic depression, and simulation-induced disruption of pathological network activity. Overall, this leads to modifications of the firing rate and pattern of neurons in the basal ganglia, as well as local release of neurotransmitters such as glutamate and adenosine. In addition, it seems that DBS also increases blood flow and stimulates neurogenesis. Over the last few years, functional imaging, specifically functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT), has been used in an attempt to clarify the mechanism of action of DBS. In fMRI, blood-oxygen-level-dependent (BOLD) signals are acquired, and oxygenated blood marks areas of neural stimulation or inhibition. On the other hand, PET and SPECT allow for imaging of multiple activity markers, such as blood flow, glucose and oxygen metabolism. While fMRI is less powerful than nuclear medicine techniques, it provides a much better spatial and temporal resolution. Because of the suspected inhibitory DBS effects in electrophysiological studies, reduced STN blood flow or glucose metabolism would have been expected on functional imaging. However, the opposite has been found to be true in an overwhelming majority of imaging studies to date. In addition, BOLD activation in the area surrounding the electrode has been reported, despite the electrode imaging artifact preventing direct observation of the STN around the electrode. This discrepancy between apparent STN inhibition in single-cell studies and activation in imaging studies might be explained by a few hypotheses. First, electrophysiological recordings identify short neuronal modulation (in the order of milliseconds) while neuroimaging methods may reflect the summed activity changes over seconds to minutes. Second, non-neuronal contributions to the change in blood flow and/or glucose metabolism cannot be excluded, and could confound the results of neuroimaging.

Finally, it is possible that PET and fMRI actually detect the increased activity in the axons, rather than in the cell bodies. Complicating matters further, some imaging studies after STN DBS have showed increased

activity in the GPi while others reported decreased activity in that nucleus. In summary, it is still unclear how exactly DBS affects the firing rate and pattern of neurons and how these changes actually modify the symptoms of Parkinson’s disease. DBS is presently more of an empirically proven treatment in search of physiological explanation.

The effect of DBS on the cardinal symptoms of PD have been established in three randomized controlled clinical trials --- 

TABLE 1

Author, year

 

No of patients

Follow up

Target

Results

Deuschl et al., 2006

156

6 months

BL STN

QOL better with DBS, motor symptom better with DBS

 

Weaver et al., 2009

255

6 months

BL STN or GPi

Dyskinesia free ON time better with DBS

 

Williams et al., 2010

366

12 months

BL STN  or GPi

QOL better with DBS

 

 

PATIENT SELECTION for DBS in PD

Patient selection is a critical first step as poorly chosen candidates may not have optimal benefits and have increased morbidity. Several factors must be considered before determining if a patient is an appropriate candidate for DBS surgery. A multidisciplinary approach involving the neurosurgeon, neurologist, and neuropsychologist is important to determine the appropriate surgical candidate. It is also important that the diagnosis of idiopathic PD be confirmed prior to proceeding with DBS surgery. Key to this assessment is evaluating the surgical candidate in both the on and off medication states with a corroborating levodopa challenge. Perhaps the best prognostic indicator of a patient’s suitability for DBS surgery is their response to levodopa.In general, a levodopa challenge following a 12-hour medication withdrawal should provide at least a 33% improvement in the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS).

                     In our institute, we follow a simple chart(below) for screening of patients for DBS in PD.

 

 

  1.  

Age<75 years

 

  •  

No

  1.  

Idiopathic PD ( No PSP/MSA/NSD etc)

 

  •  

No

  1.  

Levodopa responsive  

                      

  •  

No

  1.  

Poor/adverse response to drug          

 

  1.  Increased off period                                                              

 

  1. Disabling dyskinesia                                                              

 

 

  1. Disabling motor fluctuations                 

 

 

Yes

 

Yes

 

 

Yes

 

 

No

 

No

 

 

No

  1.  

Degree of disability(UPDRS part III score)>25

 

  •  

No

  1.  

Neuropsychology, MMSE>24

 

  •  

No

  1.  

LEVODOPA CHALLENGE RESPONSE POSITIVE                                                   

 

(30% improvement in UPDRS after 12-hours off medication)

 

  •  

No

  1.  

Advanced  co-morbidity

 

Yes

  •  
  1.  

long term anticoagulation

 

Yes

  •  
  1.  

Willing for surgery and programming

 

  •  

No

 

 

PREOPERATIVE MANAGEMENT

A full medical assessment is a necessary part of the preoperative evaluation, as advanced PD patients tend to be elderly with significant comorbidities. Major issues are---

 

Anticoagulation/antiplatelets--- The risk of discontinuing medications that affect anticoagulation and

platelet aggregation should be weighed against the potential benefits in the quality of life offered by DBS surgery. However, timely discontinuation of these latter medications is mandatory for stereotactic surgery since intracerebral hematomas are the most serious of all potential complications from DBS. Any anticlotting medications, including aspirin, ticlopidine, clopidogrel, and all nonsteroidal anti-inflammatory drugs should be discontinued at least 7 to 10 days preoperatively to ensure the return of normal blood clotting function.

Arterial hypertension can also increase the risk of intracranial bleeding during stereotactic procedures and must be controlled in the weeks prior to surgery.

A prolonged discussion on the short- and long-term effects of DBS on Parkinson’s disease should be carried out with the patient, family, and caregivers.

The night prior to DBS surgery, the antiparkinsonian medications are typically held to pronounce the Parkinson’s symptoms at the time of surgery to see the clinical effects on symptoms during surgery and the families must be counselled regarding their role in facilitating the patient.

Target selection

The two main targets considered for DBS in PD are the STN and the GPi. current tendency is to prefer targeting the STN because of a greater improvement in the OFF phase motor symptoms as well as a higher chance to decrease the medication dosage and a lower battery consumption linked to the use of lower voltage in the STN compared to the GPi DBS. GPi can be the preferred target if LID is the main complaint. GPi DBS might be preferred for patients with mild cognitive impairment and psychiatric symptoms. Because STN DBS might have a higher rate of cognitive decline and/or depression and worsening of verbal fluency in some studies.

Surgical technique

The basic components of DBS implantation surgery involve frame placement, anatomical targeting, physiological mapping, evaluation of macrostimulation thresholds for improvement in motor symptoms or induction of side effects, implantation of the DBS electrode and implantable pulse generator (IPG).

Head-frame placement

The CRW frame is the most commonly used followed by the Leksell frame. Placement of the frame is done under local anesthesia unless anxiety or uncontrollable movements necessitate the use of sedation or general anesthesia.

Leksell stereotactic frame  placed over the head of a patient showing the correct method for placement of the Leksell head-frame. The frame should be placed parallel to orbito-meatal line in order to approximate the AC-PC plane. It is attached to the patient’s head using four pins under local anesthesia.

Imaging and anatomic targeting

Computerized Tomography (CT) scans and MRI are the two main imaging modalities used for targeting when performing DBS implantations. A thin cut stereotactic CT (_2 mm slices with no gap and no gantry tilt) is obtained after frame placement and is then fused with the stereotactic MRI on a planning station (Stealth station). The advantage of fusing the CT with MRI is the ability to avoid image-distortions inherent to MR imaging adding to the stereotactic accuracy. To better define the STN, T2-weighted images (TR 2800, TE 90, flip angle 90˚, slice thickness 2.0 mm) were obtained.

The AC and the PC were marked and the centre of the AC–PC line determined. The next step is planning the entry point and trajectory. The strategy here is to avoid surface and sub-cortical vessels. After trajectory planning, the patient is placed supine on the operating table and the frame attached to the table using an adaptor. Prophylactic antibiotics are given at least 30 min prior to incision. The head is prepped and draped in a sterile fashion. Under local anesthesia, a burr-hole is placed on the calculated entry point marked on the skull. The entry point is determined by the calculated arc and ring angles. Hemostasis is achieved with bone wax and bipolar cautery.

A Medronic Stim-Loc anchoring device (Medtronic, Minneapolis, MN) burr-hole base ring is then placed on the burr-hole and secured with two screws which are used at the end of the procedure to anchor the DBS electrode.

The dura is then cauterized and opened exposing the underlying surface of the brain. The microdrive is then assembled and cannulae inserted 10 mm above the target to avoid lenticulostriate vessels found deeper. Gel- foam and fibrin glue is applied on dural hole to minimize cerebrospinal fluid (CSF) loss and air entry into the skull. Subsequently, microelectrode recording and stimulation is undertaken.

Microelectrode recording/ Mapping

Microelectrode mapping is used to precisely define the target STN and its boundaries as well as nearby critical structures. We believe microelectrode mapping is crucial in order to give one the best chance for optimal placement of the DBS lead given anatomical inaccuracies due to image distortion and intraoperative brain shifts secondary to CSF loss, and pneumocephalus that can lead to inaccuracies in defining the initial target coordinates and shifts in the target itself once the skull is opened. Microelectrode mapping is performed using platinum-iridium glass coated microelectrodes dipped in platinum black with an impedance of around 0.3–0.5 Mo. These platinum-iridium microelectrodes are capable of recording single unit activity and can also be used for micro-stimulation up to 100 mAwithout significant breakdown in their recording qualities.

As the recording electrode was advanced, entry into the STN was identified by a sudden increase in the density of cellular discharge, with the characteristic irregular pattern of discharge—spikes of different sizes, occurring at random intervals. On coming out of the STN a quiet period (background noise) was seen followed by recording from the substantia nigra if the recording was continued far enough, described as high frequency (50–60 spikes/s) discharge pattern.11 Characteristic STN recordings (visual and audio) were identified and the depth of the STN activity was noted. Identification of STN activity was only based on the visual identification. The centre of the point of best electrical activity was selected as the final target. The microelectrode was replaced with a permanent quadripolar macroelectrode (Medtronic electrode no. 3389) to target the centre of the STN electrical activity. The proximal part of this electrode consists of four nickel conductor wires insulated with a polytetrafluoroethylene jacket tubing. The distal part has four metallic noninsulated contacts of 1.5 mm spaced at 0.5 mm intervals. The diameter of the distal electrode is 1.27 mm. Based on the clinical response any of the four contacts can be used for stimulation. Macrostimulation using the DBS electrode itself is then used to determine benefits and side effects. In most cases lateral skull x rays were obtained at this point with image intensifier carefully positioned to locate the target point in the centre of the Leksell-G frame rings.

Initial programming is always refined by using intra-operative macrostimulation data and a mono-polar review to identify the thresholds of stimulation for improvement in parkinsonian motor signs as well as the thresholds for inducing side effects at the level of each contact. The four variables that are used in programming are choice of contacts (0, 1, 2 or 3 used either as the cathode or anode), frequency of stimulation (hertz), pulse-width (ms) and amplitude (voltage).

POSTOPERATIVE MANAGEMENT

In the immediate hours after surgery, it is important to keep arterial blood pressure in the normal range. In addition, the patient’s preoperative drug regimen should be restarted immediately after surgery to avoid problems with dopaminergic withdrawal. Patients should undergo postoperative CT scans and/or MRI scans to assess the electrode location and intracranial status. In addition, plain X-rays are obtained to assess the location and geometry of the leads and hardware. Parkinson’s medications may need to be adjusted depending on the patient’s status. Cognitive and behavioral changes may occur in the postoperative period, particularly in older patients. Patients can be discharged as early as 24 hours after surgery, depending on their neurological and cognitive status.

Conclusion

For the last 50 years, levodopa has been the cornerstone of PD management. However, a majority of patients develop motor fluctuations and/or LID about 5 years after the initiation of therapy. DBS of the STN or the GPI grant to patients with PD improved quality of life and decreased motor complications, and has been approved as such by the Food and Drug Administration in the US in 2002. We reviewed the experience and available literature on DBS for Parkinson’s disease over the last decade and arrive at the following understandings.

The success of DBS surgery depends on the accurate placement of the leads and meticulous programming of the stimulation. Therefore, it is best accomplished by an experienced team of neurosurgeon, neurologist, and support staff dedicated to the treatment.

Reports of surgical complication rates and long-term side-effects of DBS are very variable, so benefits and potential adverse results should not be under- or over-emphasized.

While essentially equal in improving the motor symptoms of PD, STN and GPi might have their own benefits and risks, and the choice of the target should be individualized and adapted to the patient’s situation.

Knowledge to further improve DBS treatment for Parkinson’s disease, such as a more scientific and reliable protocol on programming, strategies to minimize cognitive and psychiatric complications, and the better

long-term maintenance of the implanted device, are still lacking.

Data on the impact of DBS on non-motor symptoms affecting the quality of life of PD patients, such as pain, speech or gastro-intestinal complaints, are still scarce. Further research in these areas will help make this useful treatment even more beneficial.

3 people found this helpful

My friend is suffering from intense migraine and is unable to even sleep. What can help?

BAMS
Ayurveda, Bangalore
Hi, take tab. Shirashooladi vajra ras 1-1-1 with ginger juice. Apply ginger paste on the forehead. Instill cephagraine nasal drops 2 drops to each nostril 3 time a day.
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I am having a voice problem the words spoke by me could not be understandable to the another man to whom I answered it is because I have paralysis 3 years back which I recovered but the voice is not proper.

PDDM, MHA, MBBS
General Physician, Nashik
Breathe deeply and exhale on a hisssssssing sound. Repeat 10 times. Proper breathing is the foundation for a healthy voice AND control over nervous energy that can make the voice quiver. Say “Mm-mmm (as in yummy) Mmm-hmm (like yes) ” Repeat 5 times. This develops mask resonance, which creates a clean and vibrant sound by creating a clean approximation of the cords and a resonance that will sound great and project easily. Say “Mm-mmm. Mmm-hmm.” up and down your vocal range, from low to middle to high and back again, 10 times.
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I have the problem of fits (epilepsy) since 2008. It happens one or two times in a year. As it gives no symptoms like headache etc. Before it. Why this is happened? I took treatment in two hospitals. All the reports are normal. Doctor suggested to take tablets eptoin 100 mg twice a daily upto lifetime. Is it have any side effects?

DM - Neurology
Neurologist, Rajkot
I have the problem of fits (epilepsy) since 2008. It happens one or two times in a year. As it gives no symptoms like...
In epilepsy, your reports can be normal when it is called idiopathic epilepsy. Lf the seizures are not controlled with eptoin you require increase in dose or change in medicines. The side effects of eptoin are giddiness, hair growth, sedation, tremors, bone loss due to vit d def, anemia, etc.
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Hi sir, before 7 months I had a seizure in sleep. Aftr than 3 days before I had the same. I had an eeg and something is abnormal in the report. Pls tell me what is the cause for that sudden seizure. None in my family has it.

Ph.D - Ayurveda, MD - Ayurveda, Diploma in Diet and Nutrition, Bachelor of Ayurveda, Medicine and Surgery (BAMS), Diploma Yoga
Ayurveda, Jaipur
Hi sir, before 7 months I had a seizure in sleep. Aftr than 3 days before I had the same. I had an eeg and something ...
Dear Arun, regarding ur seizures - Ceratinly Ayurveda's Shirodhara nad Nasyam Therapies will be beneficial for you along with allopathic treatment. as allopathic treatment will prevent the relapse os the seizures in future ayurveda's therapies will give strength to ur brain nerves and maintain their normal functions. Shirodhara - would completely take the stress out of ur body and u will feel light, fresh and full of energy. Although some herbal medicines might also help you but after proper history taking. For that u may consult me privately over Lyberate. Please update with ur valuable feedback.
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Sir while walking too much I feel like something is obstructing my breath I feel shakiness while walking. Feeling of numbness in brain regions.

FRHS, Ph.D Neuro , MPT - Neurology Physiotherapy, D.Sp.Med, DPHM (Health Management ), BPTh/BPT
Physiotherapist, Chennai
Sir while walking too much I feel like something is obstructing my breath I feel shakiness while walking. Feeling of ...
Do take balanced diet and avoid stress anxiety and anticipating the things do regular physical activity and breathing exercises for about 30 minutes regularly best wishes.
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I am 76 years old. Suffering from insomnia. I could hardly get two to three hr sleep at night n next day feel loose headache .l am a diabetic nBP patient but under control. I shall be grateful if you could kindly suggest effective homeopathy medicine.

FRHS, Ph.D Neuro , MPT - Neurology Physiotherapy, D.Sp.Med, DPHM (Health Management ), BPTh/BPT
Physiotherapist, Chennai
I am 76 years old. Suffering from insomnia. I could hardly get two to three hr sleep at night n next day feel loose h...
Do Take balanced diet and hyderated Avoid stress anxiety and anticipating the things Do regular physical activity and breathing exercises for about 20 minutes regularly Best Wishes
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I have severe headache and doctors told that its migraine. What medicines or treatment should I take up to cop with this?

Diploma in Child Health (DCH), MBBS
General Physician, Bangalore
I have severe headache and doctors told that its migraine. What medicines or treatment should I take up to cop with t...
Madam, Check BP What investigations have been done What medicines have been adviced Contact me with details for proper medical advice.
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