Can Deep Brain Stimulation Withdrawal Syndromes Be Avoided by Removing Infected Implanted Pulse Generator and Cables with Contralateral Replacement in the Same Session?

Abstract

Objective: Infections are feared complications following deep brain stimulation in 1.9 to 17.6% of cases. These infections can necessitate the removal of implants, which carries the risk of life-threatening withdrawal syndromes, especially in patients suffering from Parkinson’s disease. In this report, we describe our procedure of removing an infected implanted pulse generator (IPG) and cables with contralateral replacement in the same session. Methods: We retrospectively analysed all patients with transpositions of an IPG and cables between 2017 and 2020 in a single-centre, university hospital setting. Medical records of all patients undergoing this particular surgical procedure were systematically reviewed. The shortest follow-up time was 12 months. Results: Between 2017 and 2020, we had 6 patients with a high risk of withdrawal syndrome in whom an infected IPG with cables was removed and replaced on the opposite side in the same session. There were postoperative complications in 2 patients: in one, the generator had to be re-affixed, and in the second, a skin transplant was required over one electrode because of skin necrosis. No case of invasive infection was seen, and the stimulation therapy was not interrupted. Conclusion: One-session removal of an IPG and cables with contralateral replacement seems to be an effective therapy for patients at high risk of withdrawal syndrome.

Recurrent Infections Leading to DBS Removal but Reimplantation Achieving a Good Outcome: a Case Report

“…The clinical bene ts provided by DBS are signi cant, while hardware explantation may lead to loss of e cacy and exacerbation of symptoms [10]. This is particularly problematic for PD patients, who are at signi cant risk of developing life-threatening DBS withdrawal syndrome when stimulation continues for several years [14,15].…”

Deep Brain Stimulation: Neural Tissue Response and Analysis of Adverse Events

“…This calls for complete removal of the IPG. While the surgical technique used depends on the skill of the surgeon, infections occur in 1.9-17.6% of patients [11]. The highest infection rates come from epilepsy (9.5%), dystonia (6.5%), Tourette syndrome (5.9%), and OCD (4.5%).…”

“…Complete removal of the IPG increases the risk for patients to experience DBS withdrawal syndrome [4,5,10,11]. Symptoms could include severe motor symptoms such as akinesia or rigidity in Parkinson's patients or status dystonicus in dystonia patients.…”

Implantable Pulse Generators for Deep Brain Stimulation: Challenges, Complications, and Strategies for Practicality and Longevity

“…Once the infection is cleared, IPGs can be safely re-implanted after 2-3 months (Lyons et al, 2004;Temel et al, 2004;Sillay et al, 2008;Boviatsis et al, 2010;Fenoy and Simpson, 2012). If there is a high risk of withdrawal syndrome, IPG and extension cables can be removed and a contralateral side IPG with new extensions can be implanted in the same operative session under appropriate antibiotics (Helmers et al, 2021). For patients with high stimulation settings necessitating frequent battery changes, switching to a long-lasting IPG [i.e., rechargeable Activa RC or Vercise Gevia are estimated to have life-spans of >15 years (Thrane et al, 2014;Fytagoridis et al, 2016;Helmers et al, 2018)] should be considered as a means of reducing the risk of infection from repeated surgical procedures, as well as healthcare costs (Hitti et al, 2018).…”