Complication Avoidance and Management in Deep Brain Stimulation Surgery

A number of recent publications have reviewed complications of deep brain stimulation (DBS) implantation (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11). A summary of the author's peri-operative and device-related complications using Medtronic DBS hardware is provided in Table 7.1. This is based on a series of 637 new DBS leads in 358 patients implanted by a single surgeon (PAS). Procedures were performed with frame-based stereotaxy using MRI and microelectrode recording (MER). The total incidence of unexpected returns to the operating room for management of a complication was 59 surgical cases in 50 of the 358 operated patients, or 14%. Most of these reoperations were on the subcutaneous rather than intracranial parts of the hardware. The risk of requiring further intracranial surgery to replace a broken, misplaced, or infected lead was 5.9% per patient. This chapter provides a description of our current methods for complication avoidance and management. Table 7.1 Complications in 637 DBS implants in 358 patients implanted 1998–2006. The mean follow-up time was 54 months Complication No. of occurrences No. of patients‡ Implanted leads (%) Patients (%) Hemorrhagic stroke (arterial or venous) 8 8 1.3 2.2 Ischemic stroke (capsular infarction) 1 1 0.2 0.3 Asymptomatic hemorrhage* 15 15 2.4 4.2 Stroke with permanent neurologic deficit 4 4 0.6 1.1 Chronic subdural hematoma 1 1 0.2 0.3 DBS lead fracture 5 4 1.4 1.1 Lead extender fracture 3 3 0.5 0.8 Poor initial lead position resulting in re-operation 11 10 1.7 2.8 Lead migration resulting in re-operation 2 2 0.3 0.6 Infection requiring removal of IPG and lead extender, and IV antibiotics 8 8 1.6† 2.2 Infection requiring removal of all hardware including brain leads 7 7 1.6† 2.0 Return to operating room for other exploration/repair of subcutaneous hardware⊥ 22 19 3.5 5.3 Infection requiring IV antibiotics without hardware removal (both at frontal incision) 2 2 0.3 0.6 Major air embolus (prolonging the procedure or requiring its abandonment) 3 3 0.5 0.8 Intra-operative seizure (focal) 1 1 0.2 0.3 Postoperative seizures 4 4 0.6 1.4 Tense cerebrospinal fluid collection around IPG, not surgically treated 2 2 0.3 0.6 Postoperative aspiration pneumonia 3 3 0.5 0.8 Suicide attempt or psychiatric hospitalization within 6 months of surgery 4 4 0.6 1.1 TOTAL UNPLANNED INTRACRANIAL RE-OPERATIONS 26 21 4.1 5.9 TOTAL UNPLANNED RE-OPERATIONS 59 50 9.3 14.0 ‡ The number of occurrences is greater than the number of patients affected for certain types of complications becuase there were multiple occurrences in on patient. † To calculate a “per lead implant” infection rate, an infection involving a dual-channel IPG (Kinetra) was counted as affecting two leads, while an infection of a single-channel IPG was counted as affecting one lead. * Threshold of detection was volume > 0.2 cc. ⊥ Problems included: sterile seroma around IPG, N = 2; hematoma around IPG, N = 1; hardware disconnection, N = 3; failure of wound to heal, N = 1; IPG malfunction, N = 1; elective repositioning of connector from cervical to cranial position, N = 8; lead extender replacement to address patient discomfort, N = 2; connector or IPG repositioning for threatened erosion, N = 3; repair DBS anchoring system, N = 1.