Awake Neurophysiologically Guided versus Asleep MRI-Guided STN DBS for Parkinson Disease: A Comparison of Outcomes Using Levodopa Equivalents

Abstract

Background: Deep brain stimulation (DBS) for Parkinson's disease (PD) has traditionally been performed in awake patients. Some patients are unable to tolerate awake surgery or extensive time off their medication to allow for neurophysiological testing during traditional DBS implantation, which has previously limited surgical options for these patients. Recently, asleep image-guided lead placement using intraoperative MRI or CT for verification has been proposed as an alternative for patients unable or unwilling to undergo awake DBS surgery. Methods: We conducted a retrospective chart review comparing PD patients who underwent asleep MRI-guided subthalamic nucleus (STN) DBS lead placement (n = 14) and awake neurophysiologically guided STN DBS lead placement (n = 23) at our institution. Both groups' levodopa equivalent daily doses (LEDDs) and complications at approximately 6 months of follow-up were compared, along with operative times. Results: Both groups showed statistically similar reductions in LEDD at 6 months of therapy (38.27% for awake, 49.27% for asleep; p = 0.4447), and similar complications. Operative times were initially longer for MRI-guided DBS but improved with surgical experience. Conclusion: Asleep MRI-guided DBS is a viable option for PD patients unable or unwilling to undergo awake placement, with similar results in terms of LEDD reduction and complications.

Comparison of Awake and Asleep Deep Brain Stimulation for Parkinson’s Disease: A Detailed Analysis Through Literature Review

“…This is done through the fusion of the iCT scan with the preoperative MRI scan after intracranial electrode implantation . Meanwhile, other centers use an interventional MRI (iMRI) to guide placement of DBS electrodes . As an example, the DBS group at UCSF have published their experience with bilateral STN implantation in PD patients using a first‐generation MRI system (Nexframe, high‐field interventional MR‐imaging) and then the ClearPoint system (ClearPoint interventional MRI) .…”

“…For example, target confirmation through fusion with an iCT scan in asleep DBS surgery appears to shorten the duration of surgery . While there are few published research studies using intraoperative MRI , one reported advantage is that the intraoperative (or interventional) MRI (iMRI) approach uses near real‐time acquisition of images to prospectively guide both trajectory planning and the intended targets verification before electrode placement . Therefore, interventional MRI is most useful for DBS targets that are visible on standard clinical imaging and provides a method for objective verification of intended targets .…”

Clinical outcomes following awake and asleep deep brain stimulation for Parkinson disease

“…15 Several initial series of PD patients undergoing asleep DBS have demonstrated motor and quality-of-life outcomes comparable to those in historical studies using neurophysiological testing, 9,16,22,28,29 but few reports have made direct comparisons between asleep DBS patients and control patients undergoing traditional awake surgery. 18,26 To address this gap, we report clinical outcomes for patients undergoing bilateral subthalamic nucleus (STN) or globus pallidus internus (GPi) stimulation using either awake or asleep DBS at a single institution.…”

Deep Brain Stimulation: Awake and Asleep Options

“…As greater comfort and experience is gained with this technique, operative times have improved. 29 In a retrospective analysis, surgical time was reduced by an average of 175 minutes if a single electrode was implanted without MER. 10 Such a reduction of the duration which a patient must remain on an operating room table has been suggested to decrease the risk of venous thrombosis and pulmonary embolism.…”

“…After 6 months of therapy, both groups showed statistically similar reductions in levodopa equivalent dosages. 29 …”