The Unsuccessful Twiddler: A Case of Twiddler's Syndrome Without Deep Brain Stimulator Lead Breakage

Abstract

The authors present the case of a 78-year-old right-handed female with a past medical history of Parkinson's disease, treated with implantation of a left-sided subthalamic nucleus St. Jude Medical Infinity® (Abbott Medical, Austin, TX) deep brain stimulator, who presented with leadassociated discomfort, or "bowstringing". Further investigation by chest X-ray revealed an extensive case of distal lead coiling. However, it was surprising that, despite the extensive coiling, the lead stayed intact without hardware failure as proven by patient remaining asymptomatic from her Parkinson's disease and intraoperative impedance testing demonstrating normal results. After revision surgery, the patient remained asymptomatic. Due to paucity of cases of this disease in the literature, specific predictive risk factors are not known, but certain patient characteristics may help take precautions.

Asymptomatic cable twisting in a patient with impending Twiddler syndrome detected during deep brain stimulation surgery for Parkinson’s disease: A case report

“…Additional risk factors have been reported, including psychiatric disorders, weight loss, advanced age, female sex, and looping the lead outside the pocket, as well as loss of large amounts of subcutaneous fat in previously obese women that makes them more susceptible to the IPG movement in the pocket. [7,15] Our patient with Parkinson's disease showed clinical improvement after right GPI DBS and did not recall having manipulated or moved the IPG intentionally. Identifying a tendency for the IPG to twist within the subcutaneous pocket is difficult, and it is unclear whether the movement disorder in Parkinson's disease plays a contributing role.…”

“…Additional risk factors have been reported, including psychiatric disorders, weight loss, advanced age, female sex, and looping the lead outside the pocket, as well as loss of large amounts of subcutaneous fat in previously obese women that makes them more susceptible to the IPG movement in the pocket. [ 7 , 15 ]…”

“…However, if leads have been damaged or intracranial electrodes have been pulled away, more extensive revision surgery and replacement of the hardware may be required. [ 7 ]…”

Twiddler’s syndrome after implantation of baroreflex activation therapy: a case report

“…Twiddler’s syndrome without lead breakage has been recently described in a deep brain stimulator device. 18 Despite several coils lead impedance was still within normal ranges, also after untwisting, but, nevertheless, the surgeons decided to replace the lead to minimize the possibility of acute re-coiling with consecutive lead fracture. Therefore, despite good technical values after untwisting, the lead should always be replaced, also in BAT devices, in order to ensure appropriate device function.…”

Surgical management of “Twiddler syndrome” in patients with deep brain stimulation: a technical note and review of the literature

“…Due to limited publication on TS, it is not possible so far to identify a standard therapy concept based on a surgical recommendation for TS. Some of the current case reports recommended preventing mobilization of the neurostimulator during revision surgery, either with a smaller, adapted subcutaneous pocket or with an additional fixation suture [1,3]. In 2017, Orsoro et al were able to show that fixation of the device with a nonabsorbable antimicrobial pouch instead of just fixation sutures leads to a significant reduction in the recurrence rate (0% vs. 50%, P. < 0.05) in a retrospective data analysis of 23 patients with Twiddler syndrome in cardiac devices [8].…”