Anaesthesia for deep brain stimulation and in patients with implanted neurostimulator devices

Abstract

Deep brain stimulation has become an increasingly common treatment for Parkinson's disease and other movement disorders. Consequently, it is important to understand the concepts of appropriate patient selection, the implantation process, and the various drugs and techniques that can be used to facilitate this treatment. Currently, none of the anaesthetic techniques for neurostimulator implantation has proven to be superior to others, although awake or sedation techniques are popular as they facilitate intraoperative neurological testing. However, even with meticulous anaesthetic care, perioperative complications such as hypertension and seizures do occasionally occur and close monitoring is required. Anaesthesia in patients with an implanted neurostimulator requires special considerations because of possible interference between neurostimulators and other devices. We have reviewed the current knowledge of anaesthetic techniques and perioperative complications of neurostimulator insertion. Anaesthetic considerations in patients with an implanted neurostimulator are also discussed.

Preservation of microelectrode recordings with non–GABAergic drugs during deep brain stimulator placement in children

“…15 Ketamine and remifentanil have fewer effects on spontaneous neuronal discharge during DBS placement. [11][12][13]21 The effect of mu receptor opioid agonists on the GABAergic system is less clear as there are animal studies that suggest these drugs could modulate the activity of GABA neurons via receptors located mainly at extrasynaptic sites on dendritic plasma membranes. 18 We therefore avoided the use of benzodiazepines, propofol, and volatile anesthetics and discontinued remifentanil during the MER phase.…”

“…Low-frequency pausing cells, low-frequency bursting cells, border cells, kinesthetic cells, and high frequency cells were encountered and used to assess electrode tip location. 11 The average electrode impedance was 500 kOhm. The microelectrode recordings were of sufficient quality to enable a total of 9 trajectory adjustments.…”

“…This success has encouraged the use of DBS in other movement disorders such as childhood dystonia, in which electrodes are inserted into the globus pallidus internus (GPi). 4,11,21 The procedure of inserting DBS electrodes involves initial brain imaging, placement of cranial bone fiducials or a stereotactic head frame to establish coordinates for target calculations, creation of a bur hole, and insertion of the stimulating electrode into the GPi. The neurophysiologist uses variations in spontaneous firing rates from single-unit microelectrode recordings (MERs) to identify the location of the electrode tip.…”

“…Finally, macrostimulation permits confirmation of accurate placement of the permanent electrode and observation of any clinical improvements or side effects. 11 Unfortunately, many anesthetic drugs can affect neuronal firing frequency, resulting in the inability to use MERs to guide electrode placement. 16 Because the brain is free from pain fibers, the electrode insertion part of the procedure is performed with the patient awake while receiving monitored anesthesia care or an asleep-awake-asleep technique.…”

“…16 Because the brain is free from pain fibers, the electrode insertion part of the procedure is performed with the patient awake while receiving monitored anesthesia care or an asleep-awake-asleep technique. 3,[10][11][12]14,21,22 However, young children with severe dystonia, developmental delay, and other associated cardiorespiratory conditions are not good candidates for awake procedures because their restlessness and anxiety can interfere with the operation. The unsedated patient may also have a higher risk of intracerebral bleeding from intraoperative hypertension.…”