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Sajonz BEA, Brugger TS, Reisert M, Büchsel M, Schröter N, Rau A, Egger K, Reinacher PC, Urbach H, Coenen VA, Kaller CP. Cerebral Intraparenchymal Hemorrhage due to Implantation of Electrodes for Deep Brain Stimulation: Insights from a Large Single-Center Retrospective Cross-Sectional Analysis. Brain Sci 2024; 14:612. [PMID: 38928612 PMCID: PMC11201406 DOI: 10.3390/brainsci14060612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Cerebral intraparenchymal hemorrhage due to electrode implantation (CIPHEI) is a rare but serious complication of deep brain stimulation (DBS) surgery. This study retrospectively investigated a large single-center cohort of DBS implantations to calculate the frequency of CIPHEI and identify patient- and procedure-related risk factors for CIPHEI and their potential interactions. We analyzed all DBS implantations between January 2013 and December 2021 in a generalized linear model for binomial responses using bias reduction to account for sparse sampling of CIPHEIs. As potential risk factors, we considered age, gender, history of arterial hypertension, level of invasivity, types of micro/macroelectrodes, and implanted DBS electrodes. If available, postoperative coagulation and platelet function were exploratorily assessed in CIPHEI patients. We identified 17 CIPHEI cases across 839 electrode implantations in 435 included procedures in 418 patients (3.9%). Exploration and cross-validation analyses revealed that the three-way interaction of older age (above 60 years), high invasivity (i.e., use of combined micro/macroelectrodes), and implantation of directional DBS electrodes accounted for 82.4% of the CIPHEI cases. Acquired platelet dysfunction was present only in one CIPHEI case. The findings at our center suggested implantation of directional DBS electrodes as a new potential risk factor, while known risks of older age and high invasivity were confirmed. However, CIPHEI risk is not driven by the three factors alone but by their combined presence. The contributions of the three factors to CIPHEI are hence not independent, suggesting that potentially modifiable procedural risks should be carefully evaluated when planning DBS surgery in patients at risk.
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Affiliation(s)
- Bastian E. A. Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Timo S. Brugger
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Institute for Evidence in Medicine, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Medical Physics, Department of Radiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Martin Büchsel
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Nils Schröter
- Department of Neurology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Rau
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Radiology, Tauernklinikum, 5700 Zell am See, Austria
- Paracelsus Medical Private University (PMU), 5020 Salzburg, Austria
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Fraunhofer Institute for Laser Technology (ILT), 52074 Aachen, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Volker A. Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Center for Deep Brain Stimulation, University of Freiburg, 79106 Freiburg, Germany
| | - Christoph P. Kaller
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Freiburg Optical NeuroImaging [FrONI], Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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Dos Santos B, Vaz R, Braga AC, Rito M, Lucas D, Chamadoira C. Intracerebral hemorrhage after deep brain stimulation surgery guided with microelectrode recording: analysis of 297 procedures. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:79-86. [PMID: 37865159 DOI: 10.1016/j.neucie.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/13/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVES Report the incidence of symptomatic and asymptomatic intracerebral hemorrhage (ICH) in patients submitted to deep brain stimulation (DBS) guided with microelectrode recording (MER) with further analysis of potential risk factors, both inherent to the patient and related to the pathology and surgical technique. METHODS We performed a retrospective observational study. 297 DBS procedures were concluded in 277 patients in a single hospital centre between January 2010 and December 2020. All surgeries were guided with MER. We analysed the incidence of symptomatic and asymptomatic ICH and its correlation to age, sex, diagnosis, hypertension and perioperative hypertension, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, and number of MER trajectories. RESULTS There were a total of 585 electrodes implanted in 277 patients. 16 ICH were observed, of which 6 were symptomatic and 10 asymptomatic, none of which incurred in permanent neurological deficit. The location of the hemorrhage varied between cortical and subcortical plans, always in relation with the trajectory or the final position of the electrode. The incidence of symptomatic ICH per lead-implantation was 1%, and the CT-scan demonstrated asymptomatic ICH in 1.7% more patients. Male patients or with hypertension are 2.7 and 2.2 times more likely to develop ICH, respectively. However, none of these characteristics has been shown to have a statistically significant association with the occurrence of ICH, as well as age, diagnosis, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, number of MER trajectories and perioperative hypertension. CONCLUSIONS MER-guided DBS is a safe technique, with low incidence of ICH and no permanent deficits in our study. Hypertension and male sex seem to be risk factors for the development of ICH in this surgery. Nevertheless, no statistically significant factors were found for the occurrence of this complication.
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Affiliation(s)
| | - Rui Vaz
- Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Neurosurgery Department, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
| | | | - Manuel Rito
- Neurosurgery Department, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
| | - Diana Lucas
- Neurosurgery Department, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
| | - Clara Chamadoira
- Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Neurosurgery Department, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
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Servello D, Galbiati TF, Iess G, Minafra B, Porta M, Pacchetti C. Complications of deep brain stimulation in Parkinson's disease: a single-center experience of 517 consecutive cases. Acta Neurochir (Wien) 2023; 165:3385-3396. [PMID: 37773459 DOI: 10.1007/s00701-023-05799-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The number of deep brain stimulation (DBS) procedures is rapidly rising as well as the novel indications. Reporting adverse events related to surgery and to the hardware used is essential to define the risk-to-benefit ratio and develop novel strategies to improve it. OBJECTIVE To analyze DBS complications (both procedure-related and hardware-related) and further assess potential predictive factors. METHODS Five hundred seventeen cases of DBS for Parkinson's disease were performed between 2006 and 2021 in a single center (mean follow-up: 4.68 ± 2.86 years). Spearman's Rho coefficient was calculated to search for a correlation between the occurrence of intracerebral hemorrhage (ICH) and the number of recording tracks. Multiple logistic regression analyzed the probability of developing seizures and ICH given potential risk factors. Kaplan-Meier curves were performed to analyze the cumulative proportions of hardware-related complications. RESULTS Mortality rate was 0.2%, while permanent morbidity 0.6%. 2.5% of cases suffered from ICH which were not influenced by the number of tracks used for recordings. 3.3% reported seizures that were significantly affected by perielectrode brain edema and age. The rate of perielectrode brain edema was significantly higher for Medtronic's leads compared to Boston Scientific's (Χ2(1)= 5.927, P= 0.015). 12.2% of implants reported Hardware-related complications, the most common of which were wound revisions (7.2%). Internal pulse generator models with smaller profiles displayed more favorable hardware-related complication survival curves compared to larger designs (X2(1)= 8.139, P= 0.004). CONCLUSION Overall DBS has to be considered a safe procedure, but future research is needed to decrease the rate of hardware-related complications which may be related to both the surgical technique and to the specific hardware's design. The increased incidence of perielectrode brain edema associated with certain lead models may likewise deserve future investigation.
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Affiliation(s)
- Domenico Servello
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Lombardia, Italy
| | | | - Guglielmo Iess
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Lombardia, Italy
| | - Brigida Minafra
- Parkinson's Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Mauro Porta
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Lombardia, Italy
| | - Claudio Pacchetti
- Parkinson's Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
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Optimized Deep Brain Stimulation Surgery to Avoid Vascular Damage: A Single-Center Retrospective Analysis of Path Planning for Various Deep Targets by MRI Image Fusion. Brain Sci 2022; 12:brainsci12080967. [PMID: 35892408 PMCID: PMC9332267 DOI: 10.3390/brainsci12080967] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/23/2022] Open
Abstract
Co-registration of stereotactic and preoperative magnetic resonance imaging (MRI) images can serve as an alternative for trajectory planning. However, the role of this strategy has not yet been proven by any control studies, and the trajectories of commonly used targets have not been systematically studied. The purpose of this study was to analyze the trajectories for various targets, and to assess the role of trajectories realized on fused images in preventing intracranial hemorrhage (ICH). Data from 1019 patients who underwent electrode placement for deep brain stimulation were acquired. Electrode trajectories were not planned for 396 patients, whereas trajectories were planned for 623 patients. Preoperative various MRI sequences and frame-placed MRI images were fused for trajectory planning. The patients’ clinical characteristics, the stereotactic systems, intracranial hemorrhage cases, and trajectory angles were recorded and analyzed. No statistically significant differences in the proportions of male patients, patients receiving local anesthesia, and diseases or target distributions (p > 0.05) were found between the trajectory planning group and the non-trajectory planning group, but statistically significant differences were observed in the numbers of both patients and leads associated with symptomatic ICH (p < 0.05). Regarding the ring and arc angle values, statistically significant differences were found among various target groups (p < 0.05). The anatomic structures through which leads passed were found to be diverse. Trajectory planning based on MRI fusion is a safe technique for lead placement. The electrode for each given target has its own relatively constant trajectory.
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Koh EJ, Golubovsky JL, Rammo R, Momin A, Walter B, Fernandez HH, Machado A, Nagel SJ. Estimating the Risk of Deep Brain Stimulation in the Modern Era: 2008 to 2020. Oper Neurosurg (Hagerstown) 2021; 21:277-290. [PMID: 34392372 DOI: 10.1093/ons/opab261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly. OBJECTIVE To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery. METHODS PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients. RESULTS The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%. CONCLUSION This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.
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Affiliation(s)
- Eun Jeong Koh
- Department of Neurosurgery, Jeonbuk National University Medical School, Jeonju, Jeonbuk, Republic of Korea
| | - Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arbaz Momin
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Benjamin Walter
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hubert H Fernandez
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
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Pearce P, Bulluss K, Xu SS, Kim B, Milicevic M, Perera T, Thevathasan W. How accurately are subthalamic nucleus electrodes implanted relative to the ideal stimulation location for Parkinson's disease? PLoS One 2021; 16:e0254504. [PMID: 34264988 PMCID: PMC8282046 DOI: 10.1371/journal.pone.0254504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 06/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The efficacy of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) depends on how closely electrodes are implanted relative to an individual's ideal stimulation location. Yet, previous studies have assessed how closely electrodes are implanted relative to the planned location, after homogenizing data to a reference. Thus here, we measured how accurately electrodes are implanted relative to an ideal, dorsal STN stimulation location, assessed on each individual's native imaging. This measure captures not only the technical error of stereotactic implantation but also constraints imposed by planning a suitable trajectory. METHODS This cross-sectional study assessed 226 electrodes in 113 consecutive PD patients implanted with bilateral STN-DBS by experienced clinicians utilizing awake, microelectrode guided, surgery. The error (Euclidean distance) between the actual electrode trajectory versus a nominated ideal, dorsal STN stimulation location was determined in each hemisphere on native imaging and predictive factors sought. RESULTS The median electrode location error was 1.62 mm (IQR = 1.23 mm). This error exceeded 3 mm in 28/226 electrodes (12.4%). Location error did not differ between hemispheres implanted first or second, suggesting brain shift was minimised. Location error did not differ between electrodes positioned with (48/226), or without, a preceding microelectrode trajectory shift (suggesting such shifts were beneficial). There was no relationship between location error and case order, arguing against a learning effect. DISCUSSION/CONCLUSION The proximity of STN-DBS electrodes to a nominated ideal, dorsal STN, stimulation location is highly variable, even when implanted by experienced clinicians with brain shift minimized, and without evidence of a learning effect. Using this measure, we found that assessments on awake patients (microelectrode recordings and clinical examination) likely yielded beneficial intraoperative decisions to improve positioning. In many patients the error is likely to have reduced therapeutic efficacy. More accurate methods to implant STN-DBS electrodes relative to the ideal stimulation location are needed.
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Affiliation(s)
- Patrick Pearce
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Kristian Bulluss
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Neurosurgery, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - San San Xu
- Bionics Institute, East Melbourne, Victoria, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, Victoria, Australia
- Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Boaz Kim
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | | | - Thushara Perera
- Bionics Institute, East Melbourne, Victoria, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, Victoria, Australia
| | - Wesley Thevathasan
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Topp G, Ghulam-Jelani Z, Chockalingam A, Kumar V, Byraju K, Sukul V, Pilitsis JG. Safety of Deep Brain Stimulation Lead Placement on Patients Requiring Anticlotting Therapies. World Neurosurg 2020; 145:e320-e325. [PMID: 33068799 DOI: 10.1016/j.wneu.2020.10.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Limited studies exist to support the safety of performing neuromodulation surgeries in patients whose anticlotting medication has been held. Here, we assess the safety of performing deep brain stimulation (DBS) in this patient population. METHODS All consecutive DBS patients who underwent lead and battery placement/revision at our institution between 2011 and 2020 were included in this Institutional Review Board-approved prospective outcomes database. We retrospectively recorded adverse events occurring within 90 days of surgery. RESULTS The study included 226 patients who underwent 381 lead placements in 267 surgeries. Of the 267 surgeries included in this study, 176 (66%) were performed on patients not on anticoagulants and 89 (33%) cases were on patients on 1 drug. Two (0.7%) cases involved a patient taking 2 drugs. A total of 49 adverse events were seen. Thirteen occurred in patients taking anticoagulants. There was no difference in adverse event rate between patients on anticlotting medication and those not (χ2 [1] = 1.523, P = 0.2171). No clot-related sequelae occurred in any patient. Three hemorrhages occurred, all in patients not on anticoagulants. CONCLUSIONS We found no increased risk of complications in patients routinely on anticlotting medication undergoing DBS lead placement. We show that our protocol was successful in balancing increased risks of bleeding and of thromboembolic events in this patient group.
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Affiliation(s)
- Gregory Topp
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | | | - Arun Chockalingam
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Vignessh Kumar
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Kanakaharini Byraju
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Vishad Sukul
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA; Department of Neurosurgery, Albany Medical College, Albany, New York, USA.
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