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Kähkölä J, Puhto T, Katisko J, Lahtinen M. Recommendations for the Prevention and Management of Deep Brain Stimulation Infections Based on 26-Year Single-Center Experience. Stereotact Funct Neurosurg 2024:1-8. [PMID: 38934170 DOI: 10.1159/000539188] [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: 01/25/2024] [Accepted: 04/30/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Infections related to deep brain stimulation (DBS) can lead to discontinuation of the treatment and increased morbidity. Various measures of reducing infection rates have been proposed in the literature, but scientific consensus is lacking. The aim of this study was to report a 26-year single center experience of DBS infections and provide recommendations for the prevention and management of them. METHODS The retrospective analysis consisted of 978 DBS surgeries performed at Oulu University Hospital (OUH) from 1997 to 2022. This included 342 primary or reimplantations of DBS electrodes and 559 primary or reimplantations of implantable pulse generator (IPG). Infections within approximately 1 year after the surgery without secondary cause were considered surgical-site infections (SSIs). χ2 test was used to compare infection rates before and after 2013, when the systematic implementation of infection prevention measures was started. RESULTS A total of 35 DBS implants were found to be infected. The number of SSIs was 30, of which 29 were originally operated in OUH leading to a center-specific infection rate of 3.1%. Of the SSIs, 17.2% occurred after IPG replacement. Staphylococcus aureus was found in 75.0% of cultures and 32.1% were mixed infections. The treatment of SSIs included aggressive surgical revision combined with cefuroxime and vancomycin antibiotics, as most patients in the initial conservative treatment group eventually required surgical revision. A statistically significant difference in infection rates before and after the implementation of preventative measures was not observed (risk ratio 2.20, 95% confidence interval 0.94-5.75, p = 0.051), despite over two-fold difference in the incidence of SSIs. CONCLUSION Our findings show that the rates of surgical infections are low in modern DBS, but due to their serious consequences, preventative measures should be implemented. We highlight that mixed infections should be accounted for in the antibiotic selection. Furthermore, our treatment recommendation includes aggressive surgical revision combined with antibiotic treatment.
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Affiliation(s)
- Johannes Kähkölä
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Teija Puhto
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Infectious Diseases, Oulu University Hospital, Oulu, Finland
| | - Jani Katisko
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Neurocenter, Oulu University Hospital, Oulu, Finland
| | - Maija Lahtinen
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Neurocenter, Oulu University Hospital, Oulu, Finland
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Unadkat P, Vo A, Ma Y, Peng S, Nguyen N, Niethammer M, Tang CC, Dhawan V, Ramdhani R, Fenoy A, Caminiti SP, Perani D, Eidelberg D. Deep brain stimulation of the subthalamic nucleus for Parkinson's disease: A network imaging marker of the treatment response. RESEARCH SQUARE 2024:rs.3.rs-4178280. [PMID: 38766007 PMCID: PMC11100869 DOI: 10.21203/rs.3.rs-4178280/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Subthalamic nucleus deep brain stimulation (STN-DBS) alleviates motor symptoms of Parkinson's disease (PD), thereby improving quality of life. However, quantitative brain markers to evaluate DBS responses and select suitable patients for surgery are lacking. Here, we used metabolic brain imaging to identify a reproducible STN-DBS network for which individual expression levels increased with stimulation in proportion to motor benefit. Of note, measurements of network expression from metabolic and BOLD imaging obtained preoperatively predicted motor outcomes determined after DBS surgery. Based on these findings, we computed network expression in 175 PD patients, with time from diagnosis ranging from 0 to 21 years, and used the resulting data to predict the outcome of a potential STN-DBS procedure. While minimal benefit was predicted for patients with early disease, the proportion of potential responders increased after 4 years. Clinically meaningful improvement with stimulation was predicted in 18.9 - 27.3% of patients depending on disease duration.
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Affiliation(s)
| | - An Vo
- The Feinstein Institutes for Medical Research
| | - Yilong Ma
- Center for Neurosciences, Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Shichun Peng
- Center for Neurosciences, Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | | | | | | | | | - Ritesh Ramdhani
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
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Runge J, Nagel JM, Blahak C, Kinfe TM, Heissler HE, Schrader C, Wolf ME, Saryyeva A, Krauss JK. Does Temporary Externalization of Electrodes After Deep Brain Stimulation Surgery Result in a Higher Risk of Infection? Neuromodulation 2024; 27:565-571. [PMID: 37804281 DOI: 10.1016/j.neurom.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) is a well-established surgical therapy for movement disorders that comprises implantation of stimulation electrodes and a pacemaker. These procedures can be performed separately, leaving the possibility of externalizing the electrodes for local field potential recording or testing multiple targets for therapeutic efficacy. It is still debated whether the temporary externalization of DBS electrodes leads to an increased risk of infection. We therefore aimed to assess the risk of infection during and after lead externalization in DBS surgery. MATERIALS AND METHODS In this retrospective study, we analyzed a consecutive series of 624 DBS surgeries, including 266 instances with temporary externalization of DBS electrodes for a mean of 6.1 days. Patients were available for follow-up of at least one year, except in 15 instances. In 14 patients with negative test stimulation, electrodes were removed. All kinds of infections related to implantation of the neurostimulation system were accounted for. RESULTS Overall, infections occurred in 22 of 624 surgeries (3.5%). Without externalization of electrodes, infections were noted after 7 of 358 surgeries (2.0%), whereas with externalization, 15 of 252 infections were found (6.0%). This difference was significant (p = 0.01), but it did not reach statistical significance when comparing groups within different diagnoses. The rate of infection with externalized electrodes was highest in psychiatric disorders (9.1%), followed by Parkinson's disease (7.3%), pain (5.7%), and dystonia (5.5%). The duration of the externalization of the DBS electrodes was comparable in patients who developed an infection (6.1 ± 3.1 days) with duration in those who did not (6.0 ± 3.5 days). CONCLUSIONS Although infection rates were relatively low in our study, there was a slightly higher infection rate when DBS electrodes were externalized. On the basis of our results, the indication for electrode externalization should be carefully considered, and patients should be informed about the possibility of a higher infection risk when externalization of DBS electrodes is planned.
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Affiliation(s)
- Joachim Runge
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | - Johanna M Nagel
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Thomas M Kinfe
- Division of Functional Neurosurgery, Friedrich-Alexander University, Erlangen-Nürnberg, Germany
| | - Hans E Heissler
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Marc E Wolf
- Department of Neurology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Assel Saryyeva
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Sarica C, Conner CR, Yamamoto K, Yang A, Germann J, Lannon MM, Samuel N, Colditz M, Santyr B, Chow CT, Iorio-Morin C, Aguirre-Padilla DH, Lang ST, Vetkas A, Cheyuo C, Loh A, Darmani G, Flouty O, Milano V, Paff M, Hodaie M, Kalia SK, Munhoz RP, Fasano A, Lozano AM. Trends and disparities in deep brain stimulation utilization in the United States: a Nationwide Inpatient Sample analysis from 1993 to 2017. LANCET REGIONAL HEALTH. AMERICAS 2023; 26:100599. [PMID: 37876670 PMCID: PMC10593574 DOI: 10.1016/j.lana.2023.100599] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 10/26/2023]
Abstract
Background Deep brain stimulation (DBS) is an approved treatment option for Parkinson's Disease (PD), essential tremor (ET), dystonia, obsessive-compulsive disorder and epilepsy in the United States. There are disparities in access to DBS, and clear understanding of the contextual factors driving them is important. Previous studies aimed at understanding these factors have been limited by single indications or small cohort sizes. The aim of this study is to provide an updated and comprehensive analysis of DBS utilization for multiple indications to better understand the factors driving disparities in access. Methods The United States based National Inpatient Sample (NIS) database was utilized to analyze the surgical volume and trends of procedures based on indication, using relevant ICD codes. Predictors of DBS use were analyzed using a logistic regression model. DBS-implanted patients in each indication were compared based on the patient-, hospital-, and outcome-related variables. Findings Our analysis of 104,356 DBS discharges from 1993 to 2017 revealed that the most frequent indications for DBS were PD (67%), ET (24%), and dystonia (4%). Although the number of DBS procedures has consistently increased over the years, radiofrequency ablation utilization has significantly decreased to only a few patients per year since 2003. Negative predictors for DBS utilization in PD and ET cohorts included age increase and female sex, while African American status was a negative predictor across all cohorts. Significant differences in patient-, hospital-, and outcome-related variables between DBS indications were also determined. Interpretation Demographic and socioeconomic-based disparities in DBS use are evident. Although racial disparities are present across all indications, other disparities such as age, sex, wealth, and insurance status are only relevant in certain indications. Funding This work was supported by Alan & Susan Hudson Cornerstone Chair in Neurosurgery at University Health Network.
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Affiliation(s)
- Can Sarica
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Christopher R. Conner
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Andrew Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Melissa M. Lannon
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nardin Samuel
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Colditz
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Brendan Santyr
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Clement T. Chow
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - David H. Aguirre-Padilla
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery, Medical School, Universidad de Chile, Santiago, Chile
| | - Stefan Thomas Lang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Artur Vetkas
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery, Tartu University Hospital, University of Tartu, Tartu, Estonia
| | - Cletus Cheyuo
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ghazaleh Darmani
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Oliver Flouty
- Department of Neurosurgery, University of South Florida, Tampa, FL, United States
| | - Vanessa Milano
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Michelle Paff
- Department of Neurosurgery, University of California Irvine, Orange, CA, United States
| | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
- KITE, University Health Network, Toronto, ON, Canada
| | - Renato P. Munhoz
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Alfonso Fasano
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
- KITE, University Health Network, Toronto, ON, Canada
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
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Kusyk DM, Meinert J, Stabingas KC, Yin Y, Whiting AC. Systematic Review and Meta-Analysis of Responsive Neurostimulation in Epilepsy. World Neurosurg 2022; 167:e70-e78. [PMID: 35948217 DOI: 10.1016/j.wneu.2022.07.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Neuromodulatory implants provide promising alternatives for patients with drug-resistant epilepsy (DRE) in whom resective or ablative surgery is not an option. Responsive neurostimulation (RNS) operates a unique "closed-loop" system of electrocorticography-triggered stimulation for seizure control. A comprehensive review of the current literature would be valuable to guide clinical decision-making regarding RNS. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols, a systematic PubMed literature review was performed to identify appropriate studies involving patients undergoing RNS for DRE. Full texts of included studies were analyzed and extracted data regarding demographics, seizure reduction rate, responder rate (defined as patients with >50% seizure reduction), and complications were compiled for comprehensive statistical analysis. RESULTS A total of 313 studies were screened, and 17 studies were included in the final review, representative of 541 patients. Mean seizure reduction rate was 68% (95% confidence interval 61%-76%), and the mean responder rate was 68% (95% confidence interval 60%-75%). Complications occurred in 102 of 541 patients, for a complication rate of 18.9%. A strong publication bias toward greater seizure reduction rate and increased responder rate was demonstrated among included literature. CONCLUSIONS A meta-analysis of recent RNS for DRE literature demonstrates seizure reduction and responder rates comparable with other neuromodulatory implants for epilepsy, demonstrating both the value of this intervention and the need for further research to delineate the optimal patient populations. This analysis also demonstrates a strong publication bias toward positive primary outcomes, highlighting the limitations of current literature. Currently, RNS data are optimistic for the treatment of DRE but should be interpreted cautiously.
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Affiliation(s)
- Dorian M Kusyk
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Justin Meinert
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Yue Yin
- Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Alexander C Whiting
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
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