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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Baláž M, Búřil J, Jurková T, Koriťáková E, Hrabovský D, Kunst J, Bártová P, Chrastina J. Intraoperative electrophysiological monitoring determines the final electrode position for pallidal stimulation in dystonia patients. Front Surg 2023; 10:1206721. [PMID: 37284558 PMCID: PMC10239835 DOI: 10.3389/fsurg.2023.1206721] [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: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
Background Bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective treatment for refractory dystonia. Neuroradiological target and stimulation electrode trajectory planning with intraoperative microelectrode recordings (MER) and stimulation are used. With improving neuroradiological techniques, the need for MER is in dispute mainly because of the suspected risk of hemorrhage and the impact on clinical post DBS outcome. Objective The aim of the study is to compare the preplanned GPi electrode trajectories with final trajectories selected for electrode implantation after electrophysiological monitoring and to discuss the factors potentially responsible for differences between preplanned and final trajectories. Finally, the potential association between the final trajectory selected for electrode implantation and clinical outcome will be analyzed. Methods Forty patients underwent bilateral GPi DBS (right-sided implants first) for refractory dystonia. The relationship between preplanned and final trajectories (MicroDrive system) was correlated with patient (gender, age, dystonia type and duration) and surgery characteristics (anesthesia type, postoperative pneumocephalus) and clinical outcome measured using CGI (Clinical Global Impression parameter). The correlation between the preplanned and final trajectories together with CGI was compared between patients 1-20 and 21-40 for the learning curve effect. Results The trajectory selected for definitive electrode implantation matched the preplanned trajectory in 72.5% and 70% on the right and left side respectively; 55% had bilateral definitive electrodes implanted along the preplanned trajectories. Statistical analysis did not confirm any of the studied factors as predictor of the difference between the preplanned and final trajectories. Also no association between CGI and final trajectory selected for electrode implantation in the right/left hemisphere has been proven. The percentages of final electrodes implanted along the preplanned trajectory (the correlation between anatomical planning and intraoperative electrophysiology results) did not differ between patients 1-20 and 21-40. Similarly, there were no statistically significant differences in CGI (clinical outcome) between patients 1-20 and 21-40. Conclusion The final trajectory selected after electrophysiological study differed from the preplanned trajectory in a significant percentage of patients. No predictor of this difference was identified. The anatomo-electrophysiological difference was not predictive of the clinical outcome (as measured using CGI parameter).
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Affiliation(s)
- Marek Baláž
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jiří Búřil
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Tereza Jurková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Eva Koriťáková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Dušan Hrabovský
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jonáš Kunst
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petra Bártová
- Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czechia
| | - Jan Chrastina
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
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Lu Y, Chang L, Li J, Luo B, Dong W, Qiu C, Zhang W, Ruan Y. The Effects of Different Anesthesia Methods on the Treatment of Parkinson’s Disease by Bilateral Deep Brain Stimulation of the Subthalamic Nucleus. Front Neurosci 2022; 16:917752. [PMID: 35692425 PMCID: PMC9178204 DOI: 10.3389/fnins.2022.917752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Subthalamic nucleus deep brain stimulation (STN–DBS) surgery for Parkinson’s disease (PD) is routinely performed at medical centers worldwide. However, it is debated whether general anesthesia (GA) or traditional local anesthetic (LA) is superior. Purpose This study aims to compare the effects of LA and GA operation methods on clinical improvement in patients with PD, such as motor and non-motor symptoms, after STN–DBS surgery at our center. Method A total of 157 patients with PD were retrospectively identified as having undergone surgery under LA (n = 81) or GA (n = 76) states. In this study, the Unified Parkinson’s Disease Rating Scale Motor Score (UPDRS-III) in three states, levodopa-equivalent-daily-dose (LEDD), surgical duration, intraoperative microelectrode recording (iMER) signal length, postoperative intracranial volume, electrode implantation error, neuropsychological function, quality of life scores, and complication rates were collected and compared. All patients with PD were routinely followed up at 6, 12, 18, and 24 months postoperatively. Result Overall improvement in UPDRS-III was demonstrated at postoperative follow-up, and there was no significant difference between the two groups in medication-off, stimulation-off state and medication-off, stimulation-on state. However, UPDRS-III scores in medication-on, stimulation-on state under GA was significantly lower than that in the LA group. During postoperative follow-up, LEDD in the LA group (6, 12, 18, and 24 months, postoperatively) was significantly lower than in the GA group. However, there were no significant differences at baseline or 1-month between the two groups. The GA group had a shorter surgical duration, lower intracranial volume, and longer iMER signal length than the LA group. However, there was no significant group difference in electrode implantation accuracy and complication rates. Additionally, the Hamilton Anxiety Scale (HAMA) was significantly lower in the GA group than the LA group at 1-month follow-up, but this difference disappeared at longer follow-up. Besides, there was no significant group difference in the 39-item Parkinson’s Disease Questionnaire (PDQ-39) scale scores. Conclusion Although both groups showed overall motor function improvement without a significant postoperative difference, the GA group seemed superior in surgical duration, intracranial volume, and iMER signal length. As the accuracy of electrode implantation can be ensured by iMER monitoring, DBS with GA will become more widely accepted.
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Affiliation(s)
- Yue Lu
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Chang
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Jinwen Li
- Department of Anesthesiology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Bei Luo
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Wenwen Dong
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chang Qiu
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Wenbin Zhang
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Wenbin Zhang,
| | - Yifeng Ruan
- Department of Anesthesiology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- Yifeng Ruan,
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Vesper J, Mainzer B, Senemmar F, Schnitzler A, Groiss SJ, Slotty PJ. Anesthesia for deep brain stimulation system implantation: adapted protocol for awake and asleep surgery using microelectrode recordings. Acta Neurochir (Wien) 2022; 164:1175-1182. [PMID: 35212799 PMCID: PMC8967743 DOI: 10.1007/s00701-021-05108-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/28/2021] [Indexed: 11/27/2022]
Abstract
Purpose Deep brain stimulation (DBS), an effective treatment for movement disorders, usually involves lead implantation while the patient is awake and sedated. Recently, there has been interest in performing the procedure under general anesthesia (asleep). This report of a consecutive cohort of DBS patients describes anesthesia protocols for both awake and asleep procedures. Methods Consecutive patients with Parkinson’s disease received subthalamic nucleus (STN) implants either moderately sedated or while intubated, using propofol and remifentanil. Microelectrode recordings were performed with up to five trajectories after discontinuing sedation in the awake group, or reducing sedation in the asleep group. Clinical outcome was compared between groups with the UPDRS III. Results The awake group (n = 17) received 3.5 mg/kg/h propofol and 11.6 μg/kg/h remifentanil. During recording, all anesthesia was stopped. The asleep group (n = 63) initially received 6.9 mg/kg/h propofol and 31.3 μg/kg/h remifentanil. During recording, this was reduced to 3.1 mg/kg/h propofol and 10.8 μg/kg/h remifentanil. Without parkinsonian medications or stimulation, 3-month UPDRS III ratings (ns = 16 and 52) were 40.8 in the awake group and 41.4 in the asleep group. Without medications but with stimulation turned on, ratings improved to 26.5 in the awake group and 26.3 in the asleep group. With both medications and stimulation, ratings improved further to 17.6 in the awake group and 15.3 in the asleep group. All within-group improvements from the off/off condition were statistically significant (all ps < 0.01). The degree of improvement with stimulation, with or without medications, was not significantly different in the awake vs. asleep groups (ps > 0.05). Conclusion The above anesthesia protocols make possible an asleep implant procedure that can incorporate sufficient microelectrode recording. Together, this may increase patient comfort and improve clinical outcomes.
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Affiliation(s)
- Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Bernd Mainzer
- Department of Anesthesia and Intensive Care Medicine, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Farhad Senemmar
- Department of Neurology & Institute for Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology & Institute for Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology & Institute for Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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The role of dexmedetomidine in neurosurgery. Best Pract Res Clin Anaesthesiol 2020; 35:221-229. [PMID: 34030806 DOI: 10.1016/j.bpa.2020.10.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 01/14/2023]
Abstract
Dexmedetomidine can be used for sedation and analgesia and has been approved for this use by the European Medicines Agency since 2017. It causes an arousable state of sedation, which is beneficial during neurosurgical procedures that require the patient to cooperate with neurological tests (i.e. tumor surgery or implantation of deep brain stimulators). During procedures where monitoring of somatosensory evoked potentials and/or motor evoked potentials is required, dexmedetomidine can be used as an adjunct to general anesthesia with GABAergic drugs to decrease the dose of the latter when these drugs impair the monitoring signals. The use of dexmedetomidine has also been associated with neuroprotective effects and a decreased incidence of delirium, but studies confirming these effects in the peri-operative (neuro-)surgical setting are lacking. Although dexmedetomidine does not cause respiratory depression, its hemodynamic effects are complex and careful patient selection, choice of dose, and monitoring must be performed.
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Gonzalez-Escamilla G, Muthuraman M, Ciolac D, Coenen VA, Schnitzler A, Groppa S. Neuroimaging and electrophysiology meet invasive neurostimulation for causal interrogations and modulations of brain states. Neuroimage 2020; 220:117144. [DOI: 10.1016/j.neuroimage.2020.117144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/22/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022] Open
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