Anesthetic Management of Patients Undergoing Deep Brain Stimulator Insertion

Abstract

Deep brain stimulation is used for the treatment of patients with neurologic disorders who have an alteration of function, such as movement disorders and other chronic illnesses. The insertion of the deep brain stimulator (DBS) is a minimally invasive procedure that includes the placement of electrodes into deep brain structures for microelectrode recordings and intraoperative clinical testing and connection of the DBS to an implanted pacemaker. The anesthetic technique varies depending on the traditions and requirements of each institution performing these procedures and has included monitored anesthesia with local anesthesia, conscious sedation, and general anesthesia. The challenges and demands for the anesthesiologist in the care of these patients relate to the specific concerns of the patients with functional neurologic disorders, the effects of anesthetic drugs on microelectrode recordings, and the requirements of the surgical procedure, which often include an awake and cooperative patient. The purpose of this review is to familiarize anesthesiologists with deep brain stimulation by discussing the mechanism, the effects of anesthetic drugs, and the surgical procedure of DBS insertion, and the perioperative assessment, preparation, intraoperative anesthetic management, and complications in patients with functional neurologic disorders.

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

“…21 Preservation of neurophysiological electrical activity generated from the globus pallidus is crucial for an optimal placement of the stimulating electrodes and subsequent improvement of the dystonia. Many anesthetic drugs have effects on these signals, but sedation may be required if the patient's age, emotional instability, or violent uncontrolled dystonia make them unable to tolerate the procedures while awake.…”

“…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.…”

“…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.…”

“…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.…”

Anesthetic Considerations in Patients with Parkinson Disease and Deep Brain Stimulators

“…DBS leads are carefully implanted in the brain (targeting the thalamus or basal ganglia) and connected to a pulse-generating device that is placed over the chest wall in a position similar to that used for cardiac pacemakers (on one side or both sides). 4,5 Figure 1 demonstrates a stimulator on the left chest. There are several publications discussing the anesthetic management for DBS placement, however, there is a paucity of information on intraoperative DBS management for nonneurological procedures.…”