Abstract

PurposeDeep 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.MethodsConsecutive 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.ResultsThe 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).ConclusionThe 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.

Highlights

  • Deep brain stimulation (DBS) is an effective treatment for neurodegenerative disorders with advanced motor symptoms, such as Parkinson’s disease (PD), essential tremor (ET), and dystonia

  • Infusions of propofol and remifentanil were used in all patients, as described using dosing that achieved moderate sedation in the awake group and complete general anesthesia in the asleep group

  • microelectrode recordings (MER) is not attempted in asleep procedures due to the depth of anesthesia and its effects on neuronal recordings [34]

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Summary

Introduction

Deep brain stimulation (DBS) is an effective treatment for neurodegenerative disorders with advanced motor symptoms, such as Parkinson’s disease (PD), essential tremor (ET), and dystonia. According to procedures commonly employed for the past quarter century, DBS patients are awake, sedated and treated with local anesthetics, during the procedure This enables MER for the purpose of identifying the optimal physical target and making fine adjustments in lead location. Awake procedures may extend the duration of surgery and increase the costs, findings vary on this matter [13, 23] Taking another approach, DBS implantations can be completed in asleep patients, that is, under full general anesthesia. Asleep-awake-asleep procedures have been developed to address this, in which deeper sedation is initially induced but discontinued during MER to allow the patient to wake up to the point of cooperation, and resumed for the completion of the procedure [18, 33] This approach may, see some patients who are slow to rouse from sedation or remain too groggy to participate in the MER feedback. The patients in this study are a single center subgroup from a recent report [30]

Study design
Surgical procedures
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