Parkinson's disease is defined as a chronic degenerative progressive disease of the central nervous system, which occurs with the depletion of a substance called "dopamine" in the brain and is usually seen in advanced ages. The most basic symptoms are tremor in the hands in a “counting money” manner especially on one side of the body, slowing down in movements, not moving arms while walking and sticking them to the body; Facial condition that can be expressed as “mask face” with dulling of gaze and decrease in facial expressions, walking with small steps and leaning forward. Since the main problem in Parkinson's disease is a substance deficiency in the brain, patients generally respond well to medical treatment, and it is possible to treat asignificant group of patients with drugs at an early stage. In the advanced stages of the disease, cases where medical treatment is not sufficient can be observed. In such cases when tremors do not respond to all kinds of treatmentat an early stage, treatment methods called Functional Neurosurgery applications and especially today in modern medicine called Dep Brain Stimulation can provide significant benefits.

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In diseases related to tremor, complaints are often observed as tremors at rest. Parkinson's disease is one of these tremors. The tremors that occur at rest are mostly seen in elderly patients. Another very common tremor, apart from Parkinson's disease, is the tremor that occurs when the hands are raised and held in the air, or when performing an action, but not at rest. The cases of tremor in this group are examined under the title of “Essential tremor”. In addition to the tremors in these two groups, there are also severe tremors that occur during active movement. This type of tremor is usually seen after strokes or severe head injuries, or after diseases that commonly involve the nervous system, such as multiple sclerosis.

Essential tremor, one of the most common types of tremor, is a neurological disease that causes rhythmic tremors in various parts of the body. In essential tremor disease, unlike Parkinson's, tremors occur when patients perform an action or do something. Essential tremor is more common in society than Parkinson's. Although this type of tremor complaints are seen in younger patients, almost half of them have familial characteristics and can be transmitted to children in a hereditary way. Essential tremor is one of the most common movement disorders in the world and is 10 times more common than Parkinson's disease. Deep Brain Stimulation, a surgical method, is very beneficial for these patients at the point where medical treatment is insufficient.

Dystonia is a neurological disease characterized by muscle contractions in different parts of the body. Disease may be located on the face, neck, vocal cords, arms and legs or widely. Initially, it may be in the form of impaired handwriting, cramps in thehands or feet, twitching of the neck to one side or back, contraction andclosure of the eyelids. Speech disorders or blinking may be added to these findings. Different drugs can be used to reduce muscle contractions in dystonia patients. Botulinum toxin (Botox) treatment can be tried in patients for whommedical treatment is insufficient. With the botox injections, the transmissionof the substances secreted at the muscle and nerve junction between the cellscan be prevented and the contractions can be reduced. Since the effect of Botox will disappear after a few months, the treatment needs to be repeated. In cases where medication and botox treatment are insufficient, Deep Brain Stimulation treatment comes to the fore.

Deep Brain Stimulation surgeries are performed while the patients are awake and by considering the principle of "talk-to-talk surgery". Before the operation performed under local anesthesia, the patients feel the pain of four needles while fixing the frame which is placed on their heads in their rooms. After the frame is attached, MRI is performed to calculate the points to be reached in the brain. Then, two small holes are drilled in the skull of the patients who are operated under local anesthesia, and the electrodes that are advanced inside and the related electronic mechanism areused to listen to the sounds of the brain cells and to map the brain. In this process, the responses of the cells to this process are tested by constantly chatting with the patient. Afterwards, the brain surgery part is completed by placing the electrodes, in the last part, the battery is placed under the skin in the chest under general anesthesia, and the operation is completed by connecting the battery device to the electrodes via two extension cables placed under the skin. After Deep Brain Stimulation surgery, the neurostimulator programming process begins, which takes 2-3 weeks on average. Patients graduate by adjusting the most appropriate parameters for the patient.

In Deep Brain Stimulation surgeries, patients feel the pain of 6 needles in total. At the beginning of the surgery, a frame is attached to the patient's head. The patient feels the prick of four numbing needles during the fitting of the frame. In the surgery, the skin is anesthetized while making a small hole on both sides. Apart from this, the surgery is painless and performed by talking to the patient.

In Deep Brain stimulation surgeries, a small area of 2-3 millimeters in diameter containing the cells responsible for the disease is found in the brain and intervened there. The safest method, which ensures that the results are extremely pleasing and the risks are so low, that is, 'the right intervention in the right place', is the 'Microelectrode Recording and Stimulation Technique'. Thanks to this technique, the cells responsible for the disease in the brain are listened one by one and their correct locations are determined.In this way, the physiological map of the brain is made and the electrodes are placed in the diseased area, which is detected with an error margin of less than 80 microns.

In these interventions, the risks are relatively low in “experienced hands” compared to other operations in the field of neurosurgery. Complication risks such as brain hemorrhage, infection, weakness in the arms and legs, deterioration in speech or vision can be encountered at a rate of 1-2%..

After Deep Brain Stimulation surgery, patients "graduate" after the initial programming process, which lasts for 2-3 weeks. After this process, patients are checked again in 1.5 -2 months; When necessary, the electrical current is re-arranged by making fine adjustments, and medications are arranged. After this process, the patient is told to come for follow-up examination 3 or 4 times a year, and routine follow-up examinations are planned every 3-4months on average. During the examinations, the working status and level of the battery  are checked, and the general condition of the patient is followed by arranging the medications..

The improvement that Deep Brain Stimulation brings to patients; will be in parallel with the life of the patient and the Deep Brain Stimulator. However, since Parkinson's is a chronic progressive disease, some findings of the disease in patients with a Deep Brain Stimulator; In particular, theso-called "non-motor symptoms" such as speech, balance, and swallowing may progress slowly over time. Deep Brain Stimulation turns back the clock of the disease, allowing patients to say 'hello' again to a life close to their old healthy life. The stated findings are expected to be relatively higher in non-operated patients than in patients who underwent Deep Brain Stimulation surgery.

Deep Brain Stimulation technology is also used in the treatment of essential tremor and dystonia in addition to Parkinson's.

The greatest success with Deep Brain Stimulation surgeries is achieved inmovement disorders that do not respond adequately to medical treatment,especially Parkinson's disease. Deep Brain Stimulation technology is more common in young people in addition to Parkinson's; It is also used with success in the treatment of hand tremors called “essential tremor” that occurs during an action or a procedure, and “dystonia” that occurs with excessive and uncontrolled body contractions. In addition to these, in cases of epilepsy resistant to medical treatment; It is applied in some psychiatric disorders called “obsessive-compulsive neurosis” and “depression” and in centers abroad. Controlled studies on memory disorders, drug addictions and appetite control are still ongoing. If the results of these studies can identify common targets in the brain and reveal reproducible post-surgical success rates, I plan toapply Deep Brain Stimulation therapy in these diseases as well.

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Thanks to advanced technology in recent years, batteries that can be charged from the outside and have a life of up to 25 years , and devices with technology that can adjust the direction and intensity of electric current given to the brain are being used. While these advances increase the success rate of treatment, they also ensure that there is no need for battery replacement for a long time.

There is no change in the normal daily life of patients with a Deep Brain Stimulator. Patients can continue all kinds of sports activities such as tennis and billiards, which are not very hard and do not cause head trauma, can swim and ride a bicycle.

In some cases, surgery may not be recommended for a young patient, and surgery may be recommended for an older patient. In short, age alone is not a criterion;The answers to the questions of whether the patient will benefit from the Deep Brain Stimulation surgery, whether he is a candidate for such a surgery and whether there is a chance for treatment other than Deep Brain Stimulation surgery; Many criteria such as the mental state of the patient and the anatomical structure of the brain determine the decision for surgery. Of course, although surgery is recommended, the issue of whether the patient can undergo surgery should be checked and evaluated by experts. However, even ifthe age of the patients is advanced, since these operations are performed using local anesthesia and talking to the patient, and the patient is put to sleep for half an hour while the battery is placed in the final stage, the patient's surgery is generally allowed if there is no major obstacle.

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In general, chronic diseases such as heart, diabetes, and blood pressure do not constitute an obstacle for Deep Brain Stimulation surgery. However, let us remind you that the suitability of people for Deep Brain Stimulation surgery is determined precisely as a result of detailed examinations and consultations.

Thanks to the Deep Brain Stimulation treatment, which we define as “rewinding the clock of the disease”, people who cannot live independently and who are disconnected from social life can say 'hello again' to their old healthy days; they have the chance to live independently again, and a significant part of them have the chance to practice their professions again.

Over 30 years of clinical and surgical experience. Surgical interventions for more than 1,800 Parkinson's and other movement disorder diseases and experience of more than 1,300 Deep Brain Stimulation surgeries; It is that knowledge and experience can shorten the operation time, reduce the risks of surgical complications, and help to put the electrodes in the right place in the brain in cases where it is difficult to obtain some information. easy for patients; However, in these operations, which are extremely difficult for the physician performing the surgery, the patient who is operated awake from time to time can express that he is in distress and does not feel well; The importance of experience gains much more value, especially in these cases wherethe operation should be completed as soon as possible under stress and by acting quickly.

Multiple Sclerosis (MS) is a disease that causes brain damage in recurrent attacks. Unfortunately, deep brain stimulation cannot help with the damage developed and settled during MS attacks, nor the findings such as imbalance, weakness, difficulty in walking and speech that occur after those damage. In some patients, severe tremors may occur after MS attacks and damage, and if these tremors cannot be treated with medical treatment, Deep Brain Stimulation surgery may be beneficial in reducing these tremors. However, the patient should be evaluated in detail and the finding tobe treated should be differentiated from the findings that occur during the involvement of the cerebellum or the pathways that go to and from the cerebellum and can be defined as "incompetence".

If you couldn't find the answers to your questions, you can ask your questions on our SOLUTION CENTER page to Assoc. Prof. Dr.Ali ZIRH.

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Huntington's disease, unfortunately, is a disease that progresses not only with movement disorder, but also with involuntary movements, as well as deterioration of memory in advanced stages and a relative shortening of lifespan. Even if movement disorders can be contributed to in this disease,unfortunately, it cannot have a positive effect on the progression of the disease, memory deterioration and life expectancy. For this reason, Deep Brain Stimulation surgery cannot provide a significant benefit in these patients.

In Parkinson's patients, it is not appropriate to decide on surgery based on the patient's documents or examinations; At least, I would like to express that I do not find such an application appropriate for my own relatives. In order to make the right and the healthiest decision for the patient, it is necessary to see and evaluate the worst and best states of the patients. In our center, before recommending surgery patients are evaluated more than once with their findings without or with medication, and necessary recommendations are made after these assessments,.

Parkinson Plus Syndromes, also called Parkinsonism, are diseases that resemble Parkinson's but have some features that differ from typical Parkinson's Disease. In these cases, patients benefit partially from dopamine therapy, but unfortunately, dopamine cannot correct almost all of the disease findings, as in typical Parkinson's patients. Therefore, the response of patients to drug therapy is partial. Since Deep Brain Stimulation treatment provides benefits similar to the effects of high-dose drug therapy,unfortunately the desired benefit cannot be achieved in Parkinson Plus patients and should not be applied.

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For Young Parkinson's patients who do not respond adequately to medical treatment or who require very high drug treatment; “essential tremor” patients with tremors seen in young people or even in childhood; and in “dystonia” patients as well with uncontrolled and involuntary body contractions Deep Brain Stimulation can apply with successful results. Patients who are operated in this way and regain their health can have children with a close follow-up.

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The advantage of the Deep Brain Stimulation; It is a controllable,programmable and adjustable treatment method. When necessary, it is possible to change the electrical settings, turn off or remove the battery, in other words,it is possible for the patient to return to their pre-operative state without leaving a permanent effect/damage. For this reason, if another treatment method superior to this treatment in Parkinson's disease can be developed in the coming years, all kinds of new treatment methods can be applied to patients who have undergone neurosurgery surgery.

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Today's technology with appropriate settings enables all kinds of MR imaging and other imaging examinations to be performed on these patients in centers with adequate information and equipment.

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