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Current Anesthesiology Reports

Published in:

01-09-2016 | Neuroanesthesia (M Smith, Section Editor)

Anesthesia for Deep Brain Stimulation

Authors: Lashmi Venkatraghavan, Pirjo Manninen

Published in: Current Anesthesiology Reports | Issue 3/2016

Abstract

Purpose of Review

Deep brain stimulation is used in the treatment of patients with functional neurological disorders but has expanded to include many other disorders. The target site for stimulation is dependent on the disease and symptoms of each patient. The procedure includes imaging techniques to visualize and establish coordinates to the nuclei, electrophysiological guidance with microelectrode recordings, and testing of an awake patient.

Recent Findings

The goals of anesthesia are to provide optimal surgical conditions and patient comfort, facilitate target localization and diagnosis, and treat complications. The choice of anesthetic agents and techniques will depend not only on the specific patient population and stimulation target but also varies according to institutional practice. Monitored anesthesia care, conscious sedation, and general anesthesia have all been used successfully. Perioperative complications include intracranial hemorrhage, seizures, and venous air embolism.

Summary

The anesthetic management will continue to evolve with new developments in surgical, imaging, and monitoring techniques, and the understanding of the effects of drugs on electrophysiological recordings.

Miocinovic S, Somayajula S, Chitnis S, et al. History, applications, and mechanisms of deep brain stimulation. JAMA Neurol. 2013;70:163–71.PubMed

Benabid AL, Pollak P, Louveau A, et al. Combined (thalamotomy and stimulation) stereotactic surgery of the Vim thalamic nucleus for bilateral Parkinson disease. Appl Neurophysiol. 1987;50:344–6.PubMed

Lozano AM, Dostrovsky J, Chen R, et al. Deep brain stimulation for Parkinson’s disease: disrupting the disruption. Lancet Neurol. 2002;1:225–31.PubMed

•• Larson PS. Deep brain stimulation for movement disorders. Neurotherapeutics. 2014;11:465–74. Brain targets implanted include the thalamus (essential tremor), subthalamic nucleus (Parkinson’s disease), globus pallidus (Parkinson’s disease and dystonia) with new targets currently being explored. Future developments include brain electrodes that can steer current directionally, systems capable of “closed loop” stimulation, systems that can record and interpret regional brain activity and modify stimulation parameters in a clinically meaningful way. PubMedPubMedCentral

•• Sharma M, Naik V, Deogaonkar M. Emerging applications of deep brain stimulation. J Neurosurg Sci. 2016;60(2):242–55. This review provides an overview of emerging applications of DBS, including a summary of the published literature. The pathophysiology and aberrant neural circuits involved in these disorders are highlighted. Recent advances include closed loop systems, responsive neurostimulation systems, and optogenetics techniques.

Kalia SK, Sankar T, Lozano AM. Deep brain stimulation for Parkinson’s disease and other movement disorders. Curr Opin Neurol. 2013;26:374–80.PubMed

Kocabicak E, Temel Y, Hollig A, et al. Current perspectives on deep brain stimulation for severe neurological and psychiatric disorders. Neuropsychiatr Dis Treat. 2015;11:1051–66.PubMedPubMedCentral

Laxton AW, Lipsman N, Lozano AM. Deep brain stimulation for cognitive disorders. Handb Clin Neurol. 2013;116:307–11.PubMed

Mandat T, Koziara H, Tutaj M, et al. Thalamic deep brain stimulation for tremor among multiple sclerosis patients. Neurol Neurochir Pol. 2010;44:542–5.PubMed

10.

Yamamoto T, Katayama Y, Kobayashi K, et al. Deep brain stimulation for the treatment of vegetative state. Eur J Neurosci. 2010;32:1145–51.PubMed

11.

Benabid AL, Torres N. New targets for DBS. Parkinsonism Relat Disord. 2012;18:S21–3.PubMed

12.

• Williams NR, Foote KD, Okun MS. STN versus GPi deep brain stimulation: translating the rematch into clinical practice. Mov Disord Clin Pract. 2014;1:24–35. Interdisciplinary teams can facilitate the more patient-tailored, symptom specific DBS treatment planning and provide a more thorough analysis of the risk-benefit ratio for each patient. PubMedPubMedCentral

13.

Venkatraghavan L, Manninen P. Anesthesia for deep brain stimulation. Curr Opin Anaesthesiol. 2011;24:495–9.PubMed

14.

•• Li Q, Qian Z, Arbuthnott GW, et al. Cortical effects of deep brain stimulation implications for pathogenesis and treatment of Parkinson disease. JAMA Neurol. 2014;71:100–3. The mechanism of action of DBS is not fully understood but recent studies suggest that the activity in the motor cortical areas is directly altered by DBS by signals traveling in an antidromic fashion from the STN. PubMed

15.

Slavin KV, Thulborn KR, Wess C, et al. Direct visualization of the human subthalamic nucleus with 3T MR imaging. AJNR Am J Neuroradiol. 2006;27:80–4.PubMedPubMedCentral

16.

Cho ZH, Min HK, Oh SH. Direct visualization of deep brain stimulation targets in Parkinson’s disease with the use of 7 Tesla magnetic resonance imaging. J Neurosurg. 2010;113:639–47.PubMedPubMedCentral

17.

Sharma M, Deogaonkar M. Accuracy and safety using intraoperative O-arm during placement of deep brain stimulation electrodes without electrophysiological recordings. J Clin Neurosci. 2016;27:80–6.PubMed

18.

Burchiel KJ, McCartney S, Lee A, et al. Accuracy of deep brain stimulation electrode placement using intraoperative computed tomography without microelectrode recording. J Neurosurg. 2013;119:301–6.PubMed

19.

Foltynie T, Zrinzo L, Martinez-Torres I, et al. MRI-guided STN DBS in Parkinson’s disease without microelectrode recording: efficacy and safety. J Neurol Neurosurg Psychiatry. 2011;82:358–63.PubMed

20.

Starr PA, Martin AJ, Ostrem JL, et al. Subthalamic nucleus deep brain stimulator placement using high-field interventional magnetic resonance imaging and a skull-mounted aiming device: technique and application accuracy. J Neurosurg. 2010;112:479–90.PubMedPubMedCentral

21.

Gumprechet H, Widenka D, Lumenta C. BrainLab VectorVision neuronavigation system: technology and clinical experience in 131 cases. Neurosurgery. 1999;44:97–105.

22.

Bot M, Van den Munckhof P, Bakay R. Analysis of stereotactic accuracy in patients undergoing deep brain stimulation using Nexframe and the Leksell frame. Stereotact Funct Neurosurg. 2015;93(5):316–25.PubMed

23.

Sharma M, Rhiew R, Deogaonkar M, et al. Accuracy and precision of targeting using frameless stereotactic system in deep brain stimulator implantation surgery. Neurol India. 2014;62:503–9.PubMed

24.

Rezai AR, Kopell BH, Gross RE, et al. Deep brain stimulation for Parkinson’s disease: surgical Issues. Mov Disord. 2006;21:S197–218.PubMed

25.

Frost EA, Osborn I. Deep brain stimulation—surgery for movement disorders and Parkinson’s disease. Int Anesthesiol Clin. 2009;47:57–68.PubMed

26.

Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy and functional neurosurgery. Anesthesiol Clin. 2012;30:241–68.PubMed

27.

Grant R, Gruenbaum SE, Gerrard J. Anaesthesia for deep brain stimulation: a review. Curr Opin Anaesthesiol. 2015;28:505–10.PubMedPubMedCentral

28.

Scharpf DT, Sharma M, Deogaonkar M, et al. Practical considerations and nuances in anesthesia for patients undergoing deep brain stimulation implantation surgery. Korean J Anesthesiol. 2015;68:332–9.PubMedPubMedCentral

29.

Chakrabarti R, Ghazanwy M, Tewari A. Anesthetic challenges for deep brain stimulation: a systematic approach. N Am J Med Sci. 2014;6:359–69.PubMedPubMedCentral

30.

Sebeo J, Deiner SG, Alterman RL, et al. Anesthesia for pediatric deep brain stimulation. Anesthesiol Res Pract. 2010. doi:https://doi.org/10.1155/2010/401419.

31.

Khatib R, Ebrahim Z, Rezai A, et al. Perioperative events during deep brain stimulation: the experience at Cleveland clinic. J Neurosurg Anesthesiol. 2008;20:36–40.PubMed

32.

Venkatraghavan L, Manninen P, Mak P, et al. Anesthesia for functional neurosurgery. Review of complications. J Neurosurg Anesthesiol. 2006;18:64–7.PubMed

33.

Raz A, Eimerls D, Zaidel A, et al. Propofol decreases neuronal spiking activity in the subthalamic nucleus of Parkinsonian patients. Anesth Analg. 2010;111:1285–9.PubMed

34.

Hutchison WD, Lang AE, Dostrovsky JO, et al. Pallidal neuronal activity: implications for models of dystonia. Ann Neurol. 2003;53:480–8.PubMed

35.

Maciver MB, Bronte-Stewart HM, Henderson JM, et al. Human subthalamic neuron spiking exhibits subtle responses to sedatives. Anesthesiology. 2011;115:254–64.PubMed

36.

•• Kim W, Song IH, Lim YH, et al. Influence of propofol and fentanyl on deep brain stimulation of the subthalamic nucleus. J Korean Med Sci. 2014;29:1278–86. Continuous infusion of propofol and fentanyl did not interfere with the MER signals from the STN. The results of this study suggest that propofol and fentanyl can be used for STN DBS in patients with advanced Parkinson’s disease improving the overall experience of the patients. PubMedPubMedCentral

37.

Elias WJ, Durieux ME, Huss D, et al. Dexmedetomidine and arousal affect subthalamic neurons. Mov Disord. 2008;23:1317–20.PubMed

38.

•• Krishna V, Elias G, Sammartino F, et al. The effect of dexmedetomidine on the firing properties of STN neurons in Parkinson’s disease. Eur J Neurosci. 2015;42:2070–7. Dexmedetomidine infusion was associated with a slight increase in firing rate but a significant decrease in burst index of STN neurons. As the bursting pattern is often used to identify STN and guide electrode placement, high-dose dexmedetomidine (>0.5 μg/kg/min) should be avoided.

39.

Chen SY, Tsai ST, Lin SH, et al. Subthalamic deep brain stimulation in Parkinson’s disease under different anesthetic modalities: a comparative cohort study. Stereotact Funct Neurosurg. 2011;89:372–80.PubMed

40.

•• Hippard HK, Watcha M, Stocco AJ, et al. Preservation of microelectrode recordings with non-GABAergic drugs during deep brain stimulator placement in children. J Neurosurg Pediatr. 2014;14(3):279–86. Microelectrode recordings were preserved with a combination of dexmedetomidine and ketamine, remifentanil, and nicardipine during DBS insertion in pediatric patients. PubMed

41.

• Kwon WK, Kim JH, Lee JH, et al. Microelectrode recording (MER) findings during sleep-awake anesthesia using dexmedetomidine in deep brain stimulation surgery for Parkinson’s disease. Clin Neurol Neurosurg. 2016;143:27–33. Firing rates of GPi neurons were significantly lower with dexmedetomidine sedation when compared to no sedation. However, there were no differences in the outcomes between the groups in terms of target localization or postoperative motor scores. PubMed

42.

Sanghera MK, Grossman RG, Kalhorn CG, et al. Basal ganglia neuronal discharge in primary and secondary dystonia in patients undergoing pallidotomy. Neurosurgery. 2003;52:1358–73.PubMed

43.

•• Venkatraghavan L, Rakhman E, Krishna V, et al. The effect of general anesthesia on the microelectrode recordings from pallidal neurons in patients with dystonia. J Neurosurg Anesthesiol. 2015;28(3):256–61. There was a difference in spontaneous and evoked neuronal discharges with MER performed under general anesthesia compared with no sedation. This made target localization more difficult during general anesthesia. MER recordings during general anesthesia appeared most robust with a combination of low-dose propofol and remifentanil infusion, and a low concentration of either sevoflurane or desflurane.

44.

Rodriguez RL, Fernandez HH, Haq I, et al. Pearls in patient selection for deep brain stimulation. Neurologist. 2007;13:253–60.PubMed

45.

Poon CCM, Irvin MG. Anaesthesia for deep brain stimulation and in patients with implanted neurostimulator devices. Br J Anaesth. 2009;103:152–65.PubMed

46.

Venkatraghavan L, Luciano M, Manninen P. Anesthetic management of patients undergoing deep brain stimulation insertion. Anesth Analg. 2010;110:1138–45.PubMed

47.

Schulz U, Keh D, Barner C, et al. Bispectral index monitoring does not improve anesthesia performance in patients with movement disorders undergoing deep brain stimulating electrode implantation. Anesth Analg. 2007;104:1481–7.PubMed

48.

• Bharadwaj S, Nagappa M, Tan A, et al. Comparison of bispectral index and entropy monitoring in patients undergoing internalisation of deep brain stimulators. J Neuroanaesthesiol Crit Care. 2016;3:25–32. Both Bispectral indexand Entropy performed well in patients with movement disorders. There was a good correlation between them. Hemodynamic parameters were not reliable indicators of depth of anesthesia in these patients.

49.

Rozet I, Muangman S, Vavilala MS, et al. Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson’s disease. Anesth Analg. 2006;103:1224–8.PubMed

50.

Sassi M, Zekaj E, Grotta A, et al. Safety in the use of dexmedetomidine (precedex) for deep brain stimulation surgery: our experience in 23 randomized patients. Neuromodulation. 2013;16:401–6.PubMed

51.

Harries AM, Kausar J, Roberts SA, et al. Deep brain stimulation of the subthalamic nucleus for advanced Parkinson’s disease using general anesthesia: long-term results. J Neurosurg. 2012;116:107–13.PubMed

52.

Nakajima T, Zrinzo L, Foltynie T, et al. MRI-guided subthalamic nucleus deep brain stimulation without microelectrode recording: can we dispense with surgery under local anaesthesia? Stereotact Funct Neurosurg. 2011;89:318–25.PubMed

53.

Chen T, Mirzadeh Z, Chapple K, et al. “Asleep” deep brain stimulation for essential tremor. J Neurosurg. 2015;27:1–8.

54.

•• Asha MJ, Kausar J, Krovvidi H, et al. The effect of dopaminergic therapy on intraoperative microelectrode recordings for subthalamic deep brain stimulation under GA: can we operate on patients ‘on medications’? Acta Neurochir. 2016;158:387–93. The insertion of STN DBS under general anesthesia did not affect the physiological localization of the STN or the clinical effectiveness of the procedure. PubMed

55.

Ostrem JL, Ziman N, Galifianakis NB, et al. Clinical outcomes using ClearPoint interventional MRI for deep brain stimulation lead placement in Parkinson’s disease. J Neurosurg. 2015;23:1–9.

56.

• Mirzadeh Z, Chapple K, Lambert M, et al. Parkinson’s disease outcomes after intraoperative CT-guided “asleep” deep brain stimulation in the globus pallidus internus. J Neurosurg. 2015;9:1–6. The insertion of GPi DBS under general anesthesia by the use of direct anatomical targeting resulted in significantly better outcomes as measured by the improvement in the off-medication motor scores at 6 months after surgery.

57.

•• Chabardes S, Isnard S, Castrioto A, et al. Surgical implantation of STN-DBS leads using intraoperative MRI guidance: technique, accuracy, and clinical benefit at 1-year follow-up. Acta Neurochir. 2015;157:729–37. Intraoperative MRI guided DBS insertion increases target accuracy and also improves clinical outcome as measured by pre- and post- Unified Parkinson’s Disease Rating Scale motor score (UPDRS-3) at 1-year follow-up.PubMed

58.

Moll CK, Payer S, Gulberti A, et al. STN stimulation in general anaesthesia: evidence beyond ‘evidence-based medicine’. Acta Neurochir Suppl. 2013;117:19–25.PubMed

59.

Hu X, Jiang X, Zhou X, et al. Avoidance and management of surgical and hardware-related complications of deep brain stimulation. Stereotact Funct Neurosurg. 2010;88:296–303.PubMed

60.

Fenoy FJ, Simpson RK Jr. Risks of common complications in deep brain stimulation surgery: management and avoidance. J Neurosurg. 2014;120:132–9.PubMed

61.

Boviatsis EJ, Stavrinou LC, Themistocleous M, et al. Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature. Acta Neurochir. 2010;152:2053–62.PubMed

62.

Okun MS, Rodriguez RL, Foote KD, et al. A case-based review of troubleshooting deep brain stimulator issues in movement and neuropsychiatric disorders. Parkinsonism Relat Disord. 2008;14:532–8.PubMed

63.

Binder DK, Rau GM, Starr PA. Risk factors for hemorrhage during microelectrode-guided deep brain stimulator implantation for movement disorders. Neurosurgery. 2005;56:722–32.PubMed

64.

Gorgulho A, De Salles AA, Frighetto L, Behnke E. Incidence of hemorrhage associated with electrophysiological studies performed using macroelectrodes and microelectrodes in functional neurosurgery. J Neurosurg. 2005;102:888–96.PubMed

65.

Zrinzo L, Foltynie T, Limousin P, et al. Reducing hemorrhagic complications in functional neurosurgery: a large case series and systematic literature review. J Neurosurg. 2012;116:84–94.PubMed

66.

Hooper AK, Okun MS, Foote KD, et al. Venous air embolism in deep brain stimulation. Stereotact Funct Neurosurg. 2008;87:25–30.PubMed

67.

Johnson RD, Qadri SR, Joint C, et al. Perioperative seizures following deep brain stimulation in patients with multiple sclerosis. Br J Neurosurg. 2010;24:289–90.PubMed

68.

Morishita T, Foote KD, Burdick AP. Identification and management of deep brain stimulation intra and postoperative urgencies and emergencies: review. Parkinsonism Relat Disord. 2010;16:153–62.PubMed

69.

Poston EM, Frucht SJ. Movement disorder emergencies. J Neurol. 2008;255:2–13.PubMed

70.

Pilitsis JG, Rezai AR, Boulis NM, et al. A preliminary study of transient confusional states following bilateral subthalamic stimulation for Parkinson’s disease. Stereotact Funct Neurosurg. 2005;83:67–70.PubMed

71.

Trombetta C, Deogaonkar A, Deogaonkar M, et al. Delayed awakening in dystonia patients undergoing deep brain stimulation surgery. J Clin Neurosci. 2010;17:865–8.PubMed

72.

•• Rothlind JC, York MK, Carlson K, et al. Neuropsychological changes following deep brain stimulation surgery for Parkinson’s disease: comparisons of treatment at pallidal and subthalamic targets versus best medical therapy. J Neurol Neurosurg Psychiatry. 2015;86:622–29. A small minority of patients with Parkinson’s disease develop significant decline in neuropsychological function with DBS insertion. Both STN and GPi stimulation were associated with reduction in neuropsychological functions.

73.

Odekerken VJ, Van Laar T, Staal MJ, et al. Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson’s disease (NSTAPS study): a randomised controlled trial. Lancet Neurol. 2013;12(1):37–44.PubMed

74.

Krack P, Fraix V, Mendes A, et al. Postoperative management of subthalamic nucleus stimulation for Parkinson’s disease. Mov Disord. 2002;17:S188–97.PubMed

75.

Air EL, Ostrem JL, Sanger TD, et al. Deep brain stimulation in children: experience and technical pearls. J Neurosurg Pediatr. 2011;8(6):566–74.PubMed

76.

Starr PA, Markun LC, Larson PS, et al. Interventional MRI-guided deep brain stimulation in pediatric dystonia: first experience with the ClearPoint system. J Neurosurg Pediatr. 2014;14:400–8.PubMed

77.

• Beuter A, Lefaucheur JP, Modolo J. Closed-loop cortical neuromodulation in Parkinson’s disease: An alternative to deep brain stimulation? Clin Neurophysiol. 2014;125(5):874–85. Closed-loop cortical stimulation is an emerging technique which might offer substantial clinical benefits for patients with advanced Parkinson’s disease. PubMed

78.

• Bauer R, Martin E, Haegele-Link S, et al. Noninvasive functional neurosurgery using transcranial MR imaging-guided focused ultrasound. Parkinsonism Relat Disord. 2014;20:S197–9. Transcranial magnetic resonance imaging-guided focused ultrasound is a novel, noninvasive, alternative treatment option for patients with essential tremor and Parkinson’s disease.

79.

Lipsman N, Schwartz ML, Huang Y, et al. MR-guided focused ultrasound thalamotomy for essential tremor: a proof-of-concept study. Lancet Neurol. 2013;12:462–8.PubMed

Title: Anesthesia for Deep Brain Stimulation
Authors: Lashmi Venkatraghavan
Pirjo Manninen
Publication date: 01-09-2016
Publisher: Springer US
Published in: Current Anesthesiology Reports / Issue 3/2016
Electronic ISSN: 2167-6275
DOI: https://doi.org/10.1007/s40140-016-0165-6

At a glance: The STEP trials

Springer Medicine

Anesthesia for Deep Brain Stimulation

Abstract

Purpose of Review

Recent Findings

Summary

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

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