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Kesarwani R, Mahajan UV, Wang AS, Kilbane C, Shaikh AG, Miller JP, Sweet JA. Improved Side-Effect Stimulation Thresholds and Postoperative Transient Confusion With Asleep, Image-Guided Deep Brain Stimulation. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01042. [PMID: 38305427 DOI: 10.1227/ons.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/01/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Asleep, image-guided deep brain stimulation (DBS) is a modern alternative to awake, microelectrode recording (MER) guidance. Studies demonstrate comparable efficacy and complications between techniques, although some report lower stimulation thresholds for side effects with image guidance. In addition, few studies directly compare the risk of postoperative transient confusion (pTC) across techniques. The purpose of this study was to compare clinical efficacy, stimulation thresholds for side effects, and rates of pTC with MER-guided DBS vs intraoperative 3D-fluoroscopy (i3D-F) guidance in Parkinson's disease and essential tremor. METHODS Consecutive patients from 2006 to 2021 were identified from the departmental database and grouped as having either MER-guided DBS or i3D-F-guided DBS insertion. Directional leads were used once commercially available. Changes in Unified Parkinson's Disease Rating Scale (UPDRS)-III scores, levodopa equivalent daily dose, Fahn-Tolosa-Marin scores, and stimulation thresholds were assessed, as were rates of complications including pTC. RESULTS MER guidance was used to implant 487 electrodes (18 globus pallidus interna, GPi; 171 subthalamic nucleus; 76 ventrointermediate thalamus, VIM) in 265 patients. i3D-F guidance was used in 167 electrodes (19 GPi; 25 subthalamic nucleus; 41 VIM) in 85 patients. There were no significant differences in Unified Parkinson's Disease Rating III Scale, levodopa equivalent daily dose, or Fahn-Tolosa-Marin between groups. Stimulation thresholds for side effects were higher with i3D-F guidance in the subthalamic nucleus (MER, 2.80 mA ± 0.98; i3D-F, 3.46 mA ± 0.92; P = .002) and VIM (MER, 2.81 mA ± 1.00; i3D-F, 3.19 mA ± 1.03; P = .0018). Less pTC with i3D-F guidance (MER, 7.5%; i3D-F, 1.2%; P = .034) was also found. CONCLUSION Although clinical efficacy between MER-guided and i3D-F-guided DBS was comparable, thresholds for stimulation side effects were higher with i3D-F guidance and the rate of pTC was lower. This suggests that image-guided DBS may affect long-term side effects and pose a decreased risk of pTC.
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Affiliation(s)
- Rohit Kesarwani
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Current Affiliation: Meritas Health Neurosurgery, North Kansas City Hospital, North Kansas City, Missouri, USA
| | - Uma V Mahajan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Alexander S Wang
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Camilla Kilbane
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aasef G Shaikh
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- United States Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Jonathan P Miller
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer A Sweet
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Astalosch M, Mousavi M, Ribeiro LM, Schneider GH, Stuke H, Haufe S, Borchers F, Spies C, von Hofen-Hohloch J, Al-Fatly B, Ebersbach G, Franke C, Kühn AA, Kübler-Weller D. Risk Factors for Postoperative Delirium Severity After Deep Brain Stimulation Surgery in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2024; 14:1175-1192. [PMID: 39058451 PMCID: PMC11380232 DOI: 10.3233/jpd-230276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Background Postoperative delirium (POD) is a serious complication following deep brain stimulation (DBS) but only received little attention. Its main risk factors are higher age and preoperative cognitive deficits. These are also main risk factors for long-term cognitive decline after DBS in Parkinson's disease (PD). Objective To identify risk factors for POD severity after DBS surgery in PD. Methods 57 patients underwent DBS (21 female; age 60.2±8.2; disease duration 10.5±5.9 years). Preoperatively, general, PD- and surgery-specific predictors were recorded. Montreal Cognitive Assessment and the neuropsychological test battery CANTAB ConnectTM were used to test domain-specific cognition. Volumes of the cholinergic basal forebrain were calculated with voxel-based morphometry. POD severity was recorded with the delirium scales Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Nursing Delirium Scale (NU-DESC). Spearman correlations were calculated for univariate analysis of predictors and POD severity and linear regression with elastic net regularization and leave-one-out cross-validation was performed to fit a multivariable model. Results 21 patients (36.8%) showed mainly mild courses of POD following DBS. Correlation between predicted and true POD severity was significant (spearman rho = 0.365, p = 0.001). Influential predictors were age (p < 0.001), deficits in attention and motor speed (p = 0.002), visual learning (p = 0.036) as well as working memory (p < 0.001), Nucleus basalis of Meynert volumes (p = 0.003) and burst suppression (p = 0.005). Conclusions General but also PD- and surgery-specific factors were predictive of POD severity. These findings underline the multifaceted etiology of POD after DBS in PD. Valid predictive models must therefore consider general, PD- and surgery-specific factors.
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Affiliation(s)
- Melanie Astalosch
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Luísa Martins Ribeiro
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heiner Stuke
- Department of Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Robert Koch-Institute, Berlin, Germany
- Centre for Artificial Intelligence in Public Health Research, Germany; Berlin Center for Advanced Neuroimaging (BCAN), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Haufe
- Technische Universität, Berlin, Germany
- Robert Koch-Institute, Berlin, Germany
- Physikalisch-Technische Bundesanstalt, Berlin, Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Bassam Al-Fatly
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Georg Ebersbach
- Movement Disorders Clinic, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany
| | - Christiana Franke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin School of Mind and Brain, Humboldt - Universität zu Berlin, Berlin, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Berlin, Germany
| | - Dorothee Kübler-Weller
- Department of Neurology and Experimental Neurology, Movement Disorder and Neuromodulation Unit, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Olson MC, Shill H, Ponce F, Aslam S. Deep brain stimulation in PD: risk of complications, morbidity, and hospitalizations: a systematic review. Front Aging Neurosci 2023; 15:1258190. [PMID: 38046469 PMCID: PMC10690827 DOI: 10.3389/fnagi.2023.1258190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Parkinson's disease (PD) is a progressive and debilitating neurological disorder. While dopaminergic medication improves PD symptoms, continued management is complicated by continued symptom progression, increasing medication fluctuations, and medication-related dyskinesia. Deep brain stimulation (DBS) surgery is a well-accepted and widespread treatment often utilized to address these symptoms in advanced PD. However, DBS may also lead to complications requiring hospitalization. In addition, patients with PD and DBS may have specialized care needs during hospitalization. Methods This systematic review seeks to characterize the complications and risk of hospitalization following DBS surgery. Patient risk factors and modifications to DBS surgical techniques that may affect surgical risk are also discussed. Results It is found that, when candidates are carefully screened, DBS is a relatively low-risk procedure, but rate of hospitalization is somewhat increased for DBS patients. Discussion More research is needed to determine the relative influence of more advanced disease vs. DBS itself in increased rate of hospitalization, but education about DBS and PD is important to insure effective patient care within the hospital.
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Affiliation(s)
- Markey C. Olson
- Department of Neurology, Muhammad Ali Movement Disorders Clinic, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neurosurgery, Barrow Brain and Spine, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Holly Shill
- Department of Neurology, Muhammad Ali Movement Disorders Clinic, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Francisco Ponce
- Department of Neurosurgery, Barrow Brain and Spine, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Sana Aslam
- Department of Neurology, Muhammad Ali Movement Disorders Clinic, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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Aamodt WW, Dahodwala N, Bilker WB, Farrar JT, Willis AW. Unique characteristics of end-of-life hospitalizations in Parkinson disease. Front Aging Neurosci 2023; 15:1254969. [PMID: 37901789 PMCID: PMC10600520 DOI: 10.3389/fnagi.2023.1254969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Persons with Parkinson disease (PD) are hospitalized at higher rates, have longer lengths of stay, and are more likely to die in the hospital than age-matched peers. Although prior studies have compared inpatient outcomes between persons with and without PD, little is known about inpatient outcomes across the PD trajectory, or whether hospitalizations occurring in the last 6 months of life differ from earlier hospitalizations. Methods This cross-sectional study compared Medicare Part A and B beneficiaries aged 65 and older with a qualifying PD diagnosis who were hospitalized in 2017: decedents who died between 7/1/2017 and 12/31/2017 from all causes and were hospitalized at least once in their last 6 months of life, and non-decedents who were hospitalized between 1/1/2017 and 6/30/2017 and lived 6 or more months after discharge. End-of-life (EoL) hospitalizations were defined as those occurring in the last 6 months of life. Descriptive analyses compared patient-level variables (e.g., demographics, comorbidities, treatment intensity) and encounter-level variables (e.g., length of stay, total charges) between groups. Multivariable logistic regression models also compared rates of intensive care unit (ICU) admission and 30-day readmission between hospitalized decedents and hospitalized non-decedents, adjusting for age, sex, race/ethnicity, rural residence, and Charlson Comorbidity Index Score. Results Of 26,492 Medicare decedents with PD, 16,187 (61.1%) were hospitalized in their last 6 months of life. Of 347,512 non-decedents with PD, 62,851 (18.1%) were hospitalized in a 6-month period. Hospitalized decedents were slightly older than hospitalized non-decedents (82.3 [SD 7.40] vs. 79.5 [SD 7.54] years) and had significantly more comorbidities. Compared to non-EoL hospitalizations, EoL hospitalizations were slightly longer (5 [IQR 3-9] vs. 4 [IQR 3-7] days) and more expensive based on total charges per admission ($36,323 [IQR 20,091-69,048] vs. $32,309 [IQR 18,789-57,756]). In covariate-adjusted regression models using hospitalized non-decedents as the reference group, hospitalized decedents were more likely to experience an ICU admission (AOR 2.36; CI 2.28-2.45) and 30-day readmission (AOR 2.43; CI 2.34-2.54). Discussion Hospitalizations occurring in the last 6 months of life among persons with PD in the United States are longer, more costly, and more resource intensive than earlier hospitalizations and may stem from medical comorbidities. Once hospitalized, ICU admission and 30-day readmission may aid in prognostication and serve as markers of transition to the EoL period.
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Affiliation(s)
- Whitley W. Aamodt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Nabila Dahodwala
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Warren B. Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Allison W. Willis
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
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Nomogram for Prediction of Postoperative Delirium after Deep Brain Stimulation of Subthalamic Nucleus in Parkinson’s Disease under General Anesthesia. PARKINSON'S DISEASE 2022; 2022:6915627. [DOI: 10.1155/2022/6915627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/04/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022]
Abstract
Introduction. Postoperative delirium can increase cognitive impairment and mortality in patients with Parkinson’s disease. The purpose of this study was to develop and internally validate a clinical prediction model of delirium after deep brain stimulation of the subthalamic nucleus in Parkinson’s disease under general anesthesia. Methods. We conducted a retrospective observational cohort study on the data of 240 patients with Parkinson’s disease who underwent deep brain stimulation of the subthalamic nucleus under general anesthesia. Demographic characteristics, clinical evaluation, imaging data, laboratory data, and surgical anesthesia information were collected. Multivariate logistic regression was used to develop the prediction model for postoperative delirium. Results. A total of 159 patients were included in the cohort, of which 38 (23.90%) had postoperative delirium. Smoking (OR 4.51, 95% CI 1.56–13.02,
) was the most important risk factor; other independent predictors were orthostatic hypotension (OR 3.42, 95% CI 0.90–13.06,
), inhibitors of type-B monoamine oxidase (OR 3.07, 95% CI 1.17–8.04,
), preoperative MRI with silent brain ischemia or infarction (OR 2.36, 95% CI 0.90–6.14,
), Hamilton anxiety scale score (OR 2.12, 95% CI 1.28–3.50,
), and apolipoprotein E level in plasma (OR 1.48, 95% CI 0.95–2.29,
). The area under the receiver operating characteristic curve (AUC) was 0.76 (95% CI 0.66–0.86). A nomogram was established and showed good calibration and clinical predictive capacity. After bootstrap for internal verification, the AUC was 0.74 (95% CI 0.66–0.83). Conclusion. This study provides evidence for the independent inducing factors of delirium after deep brain stimulation of the subthalamic nucleus in Parkinson’s disease under general anesthesia. By predicting the development of delirium, our model may identify high-risk groups that can benefit from early or preventive intervention.
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Single-Stage Deep Brain Stimulator Placement for Movement Disorders: A Case Series. Brain Sci 2021; 11:brainsci11050592. [PMID: 34063572 PMCID: PMC8147611 DOI: 10.3390/brainsci11050592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022] Open
Abstract
With more than two decades of experience and thousands of patients treated worldwide, deep brain stimulation (DBS) has established itself as an efficacious and common surgical treatment for movement disorders. However, a substantial majority of patients in the United States still undergo multiple, “staged” surgeries to implant a DBS system. Despite several reports suggesting no significant difference in complications or efficacy between staged and non-staged approaches, the continued use of staging implies surgeons harbor continued reservations about placing all portions of a system during the index procedure. In an effort to eliminate multiple surgeries and simplify patient care, DBS implantations at our institution have been routinely performed in a single surgery over the past four years. Patients who underwent placement of new DBS systems at our institution from January 2016 to June 2019 were identified and their records were reviewed. Revision surgeries were excluded. Total operative time, length of stay and rates of surgical site infections, lead fracture or migration, and other complications were evaluated. This series expands the body of evidence suggesting placement of a complete DBS system during a single procedure appears to be an efficacious and well-tolerated option.
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Delirium after Deep Brain Stimulation in Parkinson's Disease. PARKINSON'S DISEASE 2021; 2021:8885386. [PMID: 33604017 PMCID: PMC7872740 DOI: 10.1155/2021/8885386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 12/05/2022]
Abstract
Deep brain stimulation is a primary treatment method that improves motor and motor complications in patients with advanced Parkinson's disease. Delirium is a common and serious complication following deep brain stimulation. However, the clinical attention toward this complication remains insufficient. Advanced age, cognitive decline, and the severity of the disease may all be risk factors for delirium. The presence of delirium may also affect cognitive function and disease prognosis. Neurotransmitters such as acetylcholine and dopamine may be involved in the occurrence of delirium. Furthermore, inflammation, the effects of microlesioning of local nuclei, and brain atrophy may also play roles in the onset of delirium. Nonpharmacological therapy appears to be the primary treatment for postoperative delirium in Parkinson's disease. The current article reviews the pathogenesis, epidemiology, prognosis, and treatment of delirium following deep brain stimulation in Parkinson's disease to help clinicians better understand this common complication and to prevent, identify, and treat it as soon as possible, as well as to provide more accurate treatment for patients.
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