Expert consensus on neurosurgical robot-assisted deep brain stimulation surgery (2026 edition)

In this article, we describe the case of a patient who, under the direction of a multidisciplinary case committee, underwent both an ablative cingulotomy and subsequent bilateral deep brain stimulation placement in the Cg25 area. Review of this case provides a means of comparing the two techniques and of illustrating what we feel are some important advantages to using stimulation in the treatment of major depression. This report also provides potential insight into common and unique mechanisms mediating the two procedures.

Movement disorder surgery Part I: historical background and principle of surgery

Although intracerebral hemorrhage is the most feared complication of deep brain stimulation (DBS) surgery, cerebral ischemic events in association with DBS surgery have only rarely been described. We therefore evaluated the role of intraoperative MRI (iMRI) for early identification of cerebral ischemic events during DBS procedures and determined how ischemic infarctions affect patients over acute and long-term periods. Between January 2010 and December 2017, 1160 DBS electrodes were implanted in 595 patients at Chinese People's Liberation Army General Hospital, with the help of iMRI. The iMRI was performed in all patients after implantation, to define the accuracy of lead placement and detect complications. A CT scan was performed on postoperative days 1 to 7. The iMRI showed that cerebral ischemic changes happened in nine (1.51% of patients, 0.78% of leads) patients. Only two (0.34%) of nine patients had an ischemic infarction in the basal ganglia, while seven (1.18%) had cortical ischemia. Six (67%) of the nine patients had long-term complications, two with mild hemiparesis, two with seizures, one with language dysfunction, and one with memory loss. Of those with a cortical ischemic infarction, only three (42.86%) of seven patients had no long-term complications. Long-term follow-up imaging showed that not all the patients recovered normal morphological structure in the area of ischemic foci. The factors of sex, age, target, and anesthesia were not related to ischemic events. In six (66.7%) cases, the entry point on the cortex or the path was not ideal. Intraoperative ischemic events are not uncommon in DBS surgery. Ischemia can cause serious permanent complications, and regions subject to severe ischemia cannot be restored; it is therefore necessary to pay careful attention to any signs of ischemia. iMRI objectively provides the basis for early diagnosis of intraoperative ischemic infarction, providing guidance for follow-up treatment. The deviation in the entry point on the cortex or in the path resulted in vascular injury; it may be the key cause of ischemic events during DBS procedures.

Since the Food and Drug Administration approved DBS, there has been a surge in the number of centers providing the procedure. There is currently no consensus regarding appropriate screening procedures, necessary training of individuals providing the therapy, the need for an interdisciplinary team, or guidelines for the management of complications. An increasing number of patients come to experienced DBS centers after unsatisfactory results from DBS surgery. An attempt is made herein to evaluate the reasons for DBS failure in a series of such patients and to make recommendations to improve overall DBS outcomes. To improve outcomes of deep brain stimulation (DBS) surgery by analyzing a series of patients who had suboptimal results from DBS. Forty-one consecutive patients complaining of suboptimal results from DBS surgery came to the University of Florida Movement Disorders Center, or to Beth Israel Movement Disorders Center, over a 24-month period. All patients had undergone implantation of DBS devices at outside medical centers. Each patient was evaluated by a movement disorders neurologist, and the complete medical record was reviewed. The DBS device for each patient was interrogated for adverse effects and programmed for maximal benefit. Postoperative imaging studies were evaluated whenever possible. The average age of patients was 63.4 years (range, 49-84 years). The indication for surgery (by record review) included 9 patients with essential tremor, 31 with Parkinson disease, and 1 with dystonia. The diagnoses after referral examination included 5 with essential tremor, 26 with Parkinson disease, 3 with Parkinson disease and dementia, 1 with Parkinson disease and essential tremor, 1 with corticobasal degeneration, 1 with dystonia, 2 with multiple system atrophy, 1 with progressive supranuclear palsy, and 1 with myoclonus. Issues related to inadequate preoperative screening: Thirty (73%) of 41 patients saw a movement disorders specialist prior to DBS implantation. Fourteen (34%) patients had neuropsychological testing, 4 (10%) did not have testing, and in 23 cases (56%), it could not be determined whether or not they were tested. Five (12%) of 41 patients had an inadequate medication trial, and 5 patients (12%) had significant cognitive dysfunction prior to their DBS implantation. Surgical and device-related complications: Nineteen (46%) of 41 patients had suboptimally placed electrodes. Seven electrodes (17%) were replaced with improvement. Three patients' devices had failed due to end of battery life, 2 had infections, and 1 had a fractured lead. Programming and medication adjustments: Seven (17%) of 41 patients had no or poor access to programming. Two patients (5%) moved, and 2 physicians (5%) moved, creating issues with access to care. Eight patients (20%) required local follow-up (they flew to remote centers to have the surgery performed). Fifteen patients (37%) were inadequately programmed and improved significantly with reprogramming. Six patients (15%) experienced partial improvement with reprogramming, and 21 patients (51%) failed to improve despite extensive reprogramming. Thirty patients (73%) benefited from medication changes, 4 (10%) had antidepressants added to their regimens, and 1 (2%) had donepezil hydrochloride added. One patient's carbidopa/levodopa (2%) was restarted after complete discontinuation. With the various postoperative interventions described, 21 (51%) of 41 patients had good outcomes, 6 (15%) had modest clinical improvement, and 14 (34%) did not improve. With appropriate intervention, 51% of patients who complained of "failed" DBS procedures ultimately had good outcomes. Thirty-four percent of these patients had persistently poor outcomes despite maximal intervention. This case series provides important insights into reasons for "DBS failure" and proposes strategies to manage patients with DBS more effectively.

To investigate the effect of using microelectrode recording (MER) on the length of time required to carry out a deep brain stimulation (DBS) procedure of the subthalamic nucleus in patients with Parkinson's disease (PD). The time required to include MER in the DBS operation was calculated for the first and second sides in 24 patients with PD. The number of microelectrodes used on each trajectory for the first and second sides, and the percentage of permanent electrodes implanted on each trajectory for the first and second sides, were quantified. The average times taken to use MER were 23.4 ± 6.2 minutes, 17.4 ± 6.5 minutes, and 41.2 ± 6.3 minutes for the first side, second side and total procedure, respectively. In 75% of patients, the permanent electrode was implanted at the planned target site for the first side, and in 61% of patients for the second side. MER extends the time required to carry out the DBS procedure. However, during surgery, it provides real-time information on the electrodes' neurophysiological locations and helps the surgical team choose an alternative target if the planned target does not produce satisfying results.

Deep Brain Stimulation for OCD in a Patient With Comorbidities: Epilepsy, Tics, Autism, and Major Depressive Disorder.

Deep brain stimulation (DBS) surgery is used to reduce motor symptoms when movement disorders are refractory to medical treatment. Post-operative brain morphology can induce electrode deformations as the brain recovers from an intervention. The inverse brain shift has a direct impact on accuracy of the targeting stage, so analysis of electrode deformations is needed to predict final positions. DBS electrode curvature was evaluated in 76 adults with movement disorders who underwent bilateral stimulation, and the key variables that affect electrode deformations were identified. Non-linear modelling of the electrode axis was performed using post-operative computed tomography (CT) images. A mean curvature index was estimated for each patient electrode. Multivariate analysis was performed using a regression decision tree to create a hierarchy of predictive variables. The identification and classification of key variables that determine electrode curvature were validated with statistical analysis. The principal variables affecting electrode deformations were found to be the date of the post-operative CT scan and the stimulation target location. The main pathology, patient's gender, and disease duration had a smaller although important impact on brain shift. The principal determinants of electrode location accuracy during DBS procedures were identified and validated. These results may be useful for improved electrode targeting with the help of mathematical models.

<h3>Objective:</h3> To compare real-world outcomes in patients with Parkinson’s disease (PD) whose Deep Brain Stimulation (DBS) leads were implanted using asleep procedures versus those patients that underwent the procedure using awake conditions. <h3>Background:</h3> DBS procedures are typically conducted with patients being awake to allow for intraoperative clinical testing and/or micro-electrode recording to confirm lead location. However, asleep DBS procedures (i.e., under general anesthesia) are becoming increasingly popular due, at least in part, to technological improvements in imaging allowing alternative lead placement confirmation and shorter procedure duration (Brodsky 2017, Chen 2018, Vinke 2022). <h3>Design/Methods:</h3> A sub-analysis of patients receiving their DBS lead implant under asleep versus awake conditions was conducted in an ongoing, large, multicenter, prospective real-world outcomes study (Vercise, Boston Scientific). Motor function (MDS-UDPRS III), quality of life (PDQ-39) and related outcomes (GIC) were collected at baseline and up to 3-years. Safety events were also collected. <h3>Results:</h3> To date, 157 patients (mean age 61.2±8.3 years; 69% male) were asleep and 433 (mean age 60.1±8.5 years; 66% male) were awake during lead placement. Patients in both groups presented with similar baseline age, duration of disease and disease state. Improvement in quality-of-life was noted in both groups with a 5.3-point improvement (n = 104) in asleep group and a 4.5-point improvement (n = 319) in awake group at 1-year. Similarly, an 18.8- and 20.9-point improvement in motor function was noted in the asleep and awake groups, respectively. <h3>Conclusions:</h3> Outcomes from this large dataset of real-world outcomes examining the outcomes following asleep versus awake DBS demonstrate an alignment with results from previous studies (Holewijn 2021; LaHue 2017). Patient outcomes show little to no difference between awake versus asleep groups. Sleep DBS procedures may offer potential for shortening the total time taken for DBS procedures and offer a viable alternative for patients. <b>Disclosure:</b> Jan Vesper has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Boston Scientific . Jan Vesper has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Medtronic . Jan Vesper has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Abbott . Jan Vesper has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Abbott . Jan Vesper has received research support from German Research Council. Dr. Deuschl has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Boston Scientific Cavion Functional Neuromodulation. The institution of Dr. Deuschl has received research support from Medtronic. Dr. Deuschl has received publishing royalties from a publication relating to health care. Lilly Chen has received personal compensation for serving as an employee of Boston Scientific . Roshini Jain has received personal compensation for serving as an employee of Boston Scientific. Roshini Jain has received stock or an ownership interest from Boston Scientific.

Background: DBS is an established treatment option in refractory dystonia, and motor outcomes have been extensively evaluated instead of the usually neglected NMS (e.g., pain). Objective: To describe the non-motor symptoms (NMS) after Deep Brain Stimulation (DBS) surgery for refractory generalized inherited/idiopathic dystonia in a prospective study. Design and setting: A prospective study that evaluated patients in the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. Methods: This study evaluated patients before and one year after DBS surgery. We applied the following scales: Burke-Fahn-Marsden Rating Scale (BFMRS), Hospital Anxiety and Depression Scale (HADS), Non-Motor Symptoms Scale for Parkinson’s Disease (NMSS-PD), Parkinson’s Disease Questionnaire-8 (PDQ8) Brief Pain Inventory (BPI), Neuropathic Pain Symptom Inventory (NPSI) and McGill pain questionnaire. Results: 11 patients (38.35 ± 11.30 years) underwent surgery (36.3% women). Motor BFMRS subscore was 64.36 ± 22.94 at baseline and 33.55 ± 17.44 after surgery (p=0.003, 47.9% improvement on motor symptoms). HADS scores remained unchanged. NMSS-PD had a significant change after DBS, from 70.91 ± 59.07 to 37.18 ± 55.05 (p=0.013, 47,5% improvement). Seven patients reported pain before DBS surgery, and after one year, four patients reported chronic pain (i.e., pain improved by 42.28%). BPI’s severity and interference scores were 4.61 ± 2.84 and 4.12 ± 2.67, respectively before surgery, and 2.79 ± 2.31 (0.00–6.25) and 1.12 ± 1.32 (0.00–3.00) after DBS (p=0.043 and p=0.028). NPSI total score was 15.29 ± 13.94 before DBS, and reduced to 2.29 ± 2.98 afterward (p=0.028). McGill’s total score was 9.00 ± 3.32 before DBS, achieving 2.71 ± 2.93 after surgery (p=0.028), mostly driven by the sensory sub-score. Conclusions: We found that DBS improves NMS in dystonia, including chronic pain, anxiety, gastrointestinal symptoms, besides the already established improvement in QoL and motor symptoms.

While deep brain stimulation (DBS) has proven to be an effective treatment for many symptoms of Parkinson disease (PD), a deterioration of axial symptoms frequently occurs, particularly for speech and swallowing. These unfavorable effects of DBS may depend on the site of stimulation. The authors made quantitative measures of jaw velocity to compare the relative effectiveness of DBS in the globus pallidus internus (GPi) or the subthalamic nucleus (STN). This was a randomized, double-blind, and longitudinal study, with matched healthy controls. The peak velocities of self-scaled and externally scaled jaw movements were studied in 27 patients with PD before and after 6 months of bilateral DBS in the GPi or the STN. A mixed-effects model was used to identify differences in jaw velocity before DBS surgery (baseline) while off and on levodopa therapy, and after 6 months of DBS (postoperative) during 4 treatment conditions (off- and on-levodopa states with and without DBS). Self-scaled jaw velocity was impaired by the DBS procedure in the STN; velocity was significantly decreased across all postoperative conditions compared with either the off- or on-levodopa baseline conditions. In contrast, the postoperative velocity in the GPi group was generally faster than the baseline off-levodopa state. Turning the DBS off and on had no effect on jaw velocity in either group. Unlike baseline, levodopa therapy postoperatively no longer increased jaw velocity in either group, and this lack of effect was not related to postoperative changes in dose. The externally scaled jaw velocity was little affected by PD, but DBS still slightly affected performance, with the STN group significantly slower than the GPi group for most conditions. The authors' results suggest that either the electrode implant in STN or the subsequent period of continuous STN stimulation negatively affected voluntary jaw velocity, including the loss of the preoperative levodopa-induced improvement. While the GPi group showed some improvement in voluntary jaw velocity postoperatively, their performance during the combination of DBS and levodopa was not different from their best medical management presurgery. The results have implications for DBS target selection, particularly for those patients with oromotor dysfunctions.

Deep brain stimulation (DBS) surgery has advanced tremendously, for both clinical applications and technology. Although DBS surgery is an overall safe procedure, rare side effects, in particular, hemorrhage, may result in devastating consequences. Although there are certain advantages with transventricular trajectories, it has been reasoned that avoidance of such trajectories would likely reduce hemorrhage. To investigate the possible impact of a transventricular trajectory as compared with a transcerebral approach on the occurrence of symptomatic and asymptomatic hemorrhage after DBS electrode placement. Retrospective evaluation of 624 DBS surgeries in 582 patients, who underwent DBS surgery for movement disorders, chronic pain, or psychiatric disorders. A stereotactic guiding cannula was routinely used for DBS electrode insertion. All patients had postoperative computed tomography scans within 24 hours after surgery. Transventricular transgression was identified in 404/624 DBS surgeries. The frequency of hemorrhage was slightly higher in transventricular than in transcerebral DBS surgeries (15/404, 3.7% vs 6/220, 2.7%). While 7/15 patients in the transventricular DBS surgery group had a hemorrhage located in the ventricle, 6 had an intracerebral hemorrhage along the electrode trajectory unrelated to transgression of the ventricle and 2 had a subdural hematoma. Among the 7 patients with a hemorrhage located in the ventricle, only one became symptomatic. Overall, a total of 7/404 patients in the transventricular DBS surgery group had a symptomatic hemorrhage, whereas the hemorrhage remained asymptomatic in all 6/220 patients in the transcerebral DBS surgery group. Transventricular approaches in DBS surgery can be performed safely, in general, when special precautions such as using a guiding cannula are routinely applied.

Objective: To determine the accuracy of intraoperative computed tomography (iCT) in localizing deep brain stimulation (DBS) electrodes by comparing this modality with postoperative magnetic resonance imaging (MRI). Background: Optimal lead placement is a critical factor for the outcome of DBS procedures and preferably confirmed during surgery. iCT offers 3-dimensional verification of both microelectrode and lead location during DBS surgery. However, accurate electrode representation on iCT has not been extensively studied. Methods: DBS surgery was performed using the Leksell stereotactic G frame. Stereotactic coordinates of 52 DBS leads were determined on both iCT and postoperative MRI and compared with intended final target coordinates. The resulting absolute differences in X (medial-lateral), Y (anterior-posterior), and Z (dorsal-ventral) coordinates (ΔX, ΔY, and ΔZ) for both modalities were then used to calculate the euclidean distance. Results: Euclidean distances were 2.7 ± 1.1 and 2.5 ± 1.2 mm for MRI and iCT, respectively (p = 0.2). Conclusion: Postoperative MRI and iCT show equivalent DBS lead representation. Intraoperative localization of both microelectrode and DBS lead in stereotactic space enables direct adjustments. Verification of lead placement with postoperative MRI, considered to be the gold standard, is unnecessary.

P096 The effect of topical vibration on pain during scalp block injections in awake craniotomy and deep brain stimulation surgeries

Awake craniotomy and deep brain stimulation (DBS) procedures require the patient to be awake and adequate anesthesia conditions are typically achieved using ascalp block. These procedures inherently involve some degree of pain from local anesthetic injections during scalp block administration. We aimed to reduce the injection pain in scalp blocks using avibration stimulus. Atotal of 56patients aged between 18and 75years undergoing awake craniotomy and DBS procedures were enrolled in the study. All patients received aloading dose of dexmedetomidine before scalp block administration. Local anesthetic injections were applied sequentially to the identically named nerves on the right and left sides of the head. Avibration device was used during injections on one side, while injections on the other side were performed without vibration. The numeric rating scale (NRS) score and hemodynamic measurements during each injection, including heart rate and mean arterial pressure were compared between vibration and nonvibration sides. The NRS scores were lower on the side where vibration was used during scalp block injections (P < 0.001). Additionally, there was adecrease in heart rate and mean arterial pressure on the side where vibration was used compared to the baseline value (P < 0.005). The study showed that using topical vibration during ascalp block can decrease the pain of alocal anesthetic injection and maintain hemodynamic stability. ClinicalTrials.gov (NCT06038825).

There are several different surgical procedures that are used to treat essential tremor (ET), including deep brain stimulation (DBS) and thalamotomy procedures with radiofrequency (RF), radiosurgery (RS) and most recently, focused ultrasound (FUS). Choosing a surgical treatment requires a careful presentation and discussion of the benefits and drawbacks of each. We conducted a literature review to compare the attributes and make an appraisal of these various procedures. DBS was the most commonly reported treatment for ET. One-year tremor reductions ranged from 53% to 63% with unilateral Vim DBS. Similar improvements were demonstrated with RF (range, 74%–90%), RS (range, 48%–63%) and FUS thalamotomy (range, 35%–75%). Overall, bilateral Vim DBS demonstrated more improvement in tremor reduction since both upper extremities were treated (range, 66%–78%). Several studies show continued beneficial effects from DBS up to five years. Long-term follow-up data also support RF and gamma knife radiosurgical thalamotomy treatments. Quality of life measures were similarly improved among patients who received all treatments. Paraesthesias, dysarthria and ataxia were commonly reported adverse effects in all treatment modalities and were more common with bilateral DBS surgery. Many of the neurological complications were transient and resolved after surgery. DBS surgery had the added benefit of programming adjustments to minimise stimulation-related complications. Permanent neurological complications were most commonly reported for RF thalamotomy. Thalamic DBS is an effective, safe treatment with a long history. For patients who are medically unfit or reluctant to undergo DBS, several thalamic lesioning methods have parallel benefits to unilateral DBS surgery. Each of these surgical modalities has its own nuance for treatment and patient selection. These factors should be carefully considered by both neurosurgeons and patients when selecting an appropriate treatment for ET.