Worried your deep brain stimulation battery will “run out” during the COVID-19 Pandemic? Two experts weigh in...
A picture of DBS from the Emory University DBS Webpage
There are many patients stuck at home worried about whether their deep brain stimulation (DBS) batteries will “run out” during the COVID-19 crisis and for some the batteries may already be depleted. Worse may be the thought that elective surgeries have been cancelled and that there may be a delay in the replacement. This delay could lead to a worrisome rebound of symptoms. We sat down with two DBS experts from the Emory University (Atlanta GA) Parkinson’s Foundation Center of Excellence to get their thoughts. Svjetlana Miocinovic is a neurologist and Robert E. Gross a neurosurgeon. Together with their team they run a busy academic DBS practice.
Dr. Svjetlana Miocinovic an expert neurologist and DBS researcher.
Dr. Robert Gross an expert neurosurgeon and DBS researcher.
What worries you the most about DBS patients during the COVID-19 crisis?
Dr. Miocinovic:
My biggest worry is that most medical centers are forced to postpone elective procedures and also defer non-urgent clinic visits. This is important to protect patients from COVID-19 infection, and to conserve hospital resources (PPE, anaesthesia time,ventilators, etc.). Many of our DBS patients are older and could have serious complications from COVID-19 infection, but at the same time they could be harmed by delays in DBS care. It is a frustrating situation because we want to provide the best care for our patients, but have to carefully weigh risks and benefits.
Dr. Gross:
I worry that deep brain stimulation patients are at risk to develop varying degrees of symptom worsening due to interruption of therapy (end of battery life). Also, some patients may experience a DBS hardware failure (lead fracture, electrical issue) from another cause and it may be difficult to help them in a timely fashion. Also, that when the restrictions are lifted, it will be challenging to get everyone treated in a timely fashion due to the backlog that is developing of people needing their IPGs replaced.
Can DBS battery failure be serious or life threatening?
Dr. Gross:
A rare complication has been observed in some Parkinson’s disease patients. This complication has been referred to as a “DBS-withdrawal syndrome.” This syndrome has been described to present with similar symptoms as sudden levodopa withdrawal or in response to antipsychotic medications (neuroleptic malignant syndrome). Symptoms include severe stiffness, difficulty speaking, difficulty swallowing, fever and confusion. It can be serious.
Dr. Miocinovic:
In the majority of cases, DBS battery failure is not life-threatening. If the DBS battery runs out or fails, a small subset of patients can develop severe dystonic cramps (status dystonicus) or continuous disabling flailing movements (dyskinesias). Patients with obsessive compulsive disorder (OCD) have been reported to become suicidal as a result of battery failure.
Dr. Gross and his team during a DBS operation.
What is the best way to care for most deep brain stimulation patients during the COVID crisis?
Dr. Miocinovic:
Outpatient care typically requires in-person interrogation and programming, however in many cases after the first 6 months very few programming changes are actually required. The DBS battery status can be monitored by the patient by using their remote control. Medications can be adjusted by using telemedicine visits or by phone consultations.
Dr. Gross:
The technology to perform remote programming is already in use in China and possibly other countries. It is unfortunate but this technology could have been useful for COVID-19 but it is not available in the U.S.A. Despite this, it is important for patients that experience issues to contact their clinicians, and if necessary, to come in person to be seen. We are able to see patients if it is urgent. And many centers such as our own have instituted telemedicine visits that can help patients decide if they need to be seen or not. For those patients without access to telemedicine, a telephone call works just as well.
Despite the risks, when is it time to say “enough is enough” and to replace the DBS battery during the COVID crisis?
Dr. Jerry Vitek an alumnus of Johns Hopkins and Emory University holds up a DBS battery. Dr. Vitek is now chair at the University of Minnesota.
Dr. Miocinovic:
If there is concern that a patient will have severe symptom rebound or may need to be hospitalized if the battery fails, we will make every effort to replace it before if it is fully depleted, despite the COVID risks. It is important for patients to keep in touch with their DBS team and to keep track of the battery charge indicator if their battery is nearing depletion. Some patients may be able to tolerate being off DBS therapy temporarily, and in those cases, it may be safer to wait until the situation normalizes.
Dr. Gross
Optimally the battery should be replaced prior to depletion. The decision for replacement should be made on a case-by-case basis and should consider:
· The battery status (fully depleted or partially depleted)
· The patient’s tolerance of DBS therapy interruption.
· Some patients may be able to defer battery replacement.
· Scheduling of the procedure depends on the hospital system regulations and triage procedures. If it is necessary, the procedure usually can be done.
· New lead implants are elective procedures and should not be routinely performed during a pandemic (rare indications only).
· DBS infection is an emergency which may require surgery.
Dr. Mahlon DeLong, former chair of Neurology at Emory and winner of the Lasker award for his work on basal ganglia circuits and also DBS.
Recommendations for Pandemic Deep Brain Stimulation Device Management led by Drs
Miocinovic and Gross (and including experiences from Emory, University of Florida and the University of California at San Francisco) will be published soon as a letter in Neurosurgery (2020).
A figure from the University of Florida Plos One paper that is publicly available.
More reading on DBS battery life can be found in the article Management of Deep Brain Stimulator Battery Failure. This is by Fakhar and colleagues at the University of Florida.
To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #EndingPD #ParkinsonPACT #Parkinsonsecrets and https://www.tourettetreatment.com/