Introduction: Deep brain stimulation (DBS) is an established treatment for the management of Parkinson's disease (PD), tremor and dystonia. Patient selection, target choice and surgical accuracy are the foundation for a successful DBS outcome. However, in some cases, revision or reimplantation is needed due to limited benefits, device failure or infection involving the hardware. There are relatively few published series describing the outcomes after lead revision or reimplantation. In this study, we present our outcomes after revision or reimplantation surgery in patients with infections, device failure or unsatisfactory results after DBS surgery for PD.

Methods: Demographic data, indication for removal or revision, procedure time, outcomes and lead location for reimplants were analyzed for all patients who underwent DBS for PD between 2010 and 2016 at our institution. The Movement Disorders Society-Unified Parkinson Disease Rating Scale – Motor subscale (MDS-UPDRS III) scores were compared prior to and 6 months after re-implantation. Lead location were analyzed before removal and after re-implant or revision.

Results: Our final sample included 25 patients who underwent 34 lead removals. Thirteen patients had eighteen leads reimplanted after removal. There was significant improvement in the motor scores after revision surgery among the patients who had the lead revised for a suboptimal outcome (p=.025). The mean vector distance of the new lead location compared to the previous location was 2.16mm (SD=1.17), measured on an axial plane 3.5 mm below the AC-PC line. When these leads were analyzed by subgroup, the mean distance was 1.67 mm (SD=0.83) among patients treated for infection and 2.73 mm (SD=1.31) for those with suboptimal outcomes.

Conclusions: Patients with Parkinson's disease who underwent reimplantation surgery due to suboptimal outcome may experience significant benefits. Reimplantation after surgical infection seems feasible and overall safe.

Patient Care: This research shows it is indeed possible to improve outcomes after limited benefit is achieved from an index implantation by revising the electrode position. While management of infection is costly, it seems that it is possible to recapture the initial gain of DBS after reimplantation.

Learning Objectives: Review the outcomes and complications after DBS lead revision or reimplant. Discuss outcomes in patients with suboptimal outcomes who underwent lead revision.

References: 1. Hamani C, Richter E, Schwalb JM, Lozano AM: Bilateral subthalamic nucleus stimulation for Parkinson’s disease: A systematic review of the clinical literature. Neurosurgery 56:1313–1321, 2005 2. Machado A, Rezai AR, Kopell BH, Gross RE, Sharan AD, Benabid A-L: Deep brain stimulation for Parkinson’s disease: surgical technique and perioperative management. Mov Disord 21 Suppl 1:S247-58, 2006 Available: http://www.ncbi.nlm.nih.gov/pubmed/16810722. 3. Deuschl G, Schade-Brittinger C, Krack P, Volkmann J, Schäfer H, Bötzel K, et al: A Randomized Trial of Deep-Brain Stimulation for Parkinson’s Disease. N Engl J Med 355:896–908, 2006 Available: http://www.ncbi.nlm.nih.gov/pubmed/16943402. 4. Ellis TM, Foote KD, Fernandez HH, Sudhyadhom A, Rodriguez RL, Zeilman P, et al: Reoperation for suboptimal outcomes after deep brain stimulation surgery. Neurosurgery 63:754–760, 2008 5. Falowski SM, Bakay RAE: Revision Surgery of Deep Brain Stimulation Leads. Neuromodulation Technol Neural Interface 2015:n/a-n/a, 2016 Available: http://doi.wiley.com/10.1111/ner.12404. 6. Okun MS, Tagliati M, Pourfar M, Fernandez HH, Rodriguez RL, Alterman RL, et al: Management of Referred Deep Brain Stimulation Failures. Arch Neurol 62:1250–1255, 2005 7. Richardson RM, Ostrem JL, Starr PA: Surgical repositioning of misplaced subthalamic electrodes in Parkinson’s disease: Location of effective and ineffective leads. Stereotact Funct Neurosurg 87:297–303, 20091. 8. Anheim M, Batir A, Fraix V, Silem M, Chabardès S, Seigneuret E, et al: Improvement in Parkinson disease by subthalamic nucleus stimulation based on electrode placement: effects of reimplantation. Arch Neurol 65:612–6, 2008 Available: http://www.ncbi.nlm.nih.gov/pubmed/18474736.