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  • Pneumocephalus and electrode deviation in deep brain stimulation for Parkinson’s disease

    Final Number:

    J. Nicole Bentley MD; Karen Cummings; Kelvin Chou; Parag G. Patil MD PhD

    Study Design:

    Subject Category:
    Functional Neurosurgery

    Meeting: 2014 ASSFN Biennial Meeting

    Introduction: Occurrence of brain shift during deep brain stimulation (DBS) may lead to deviation in electrode placement, which may reduce clinical benefit. Intracranial air (ICA) has been cited as one potential factor influencing the amount of shift. We analyzed a series of patients with ICA after DBS to better understand the impact on electrode position and clinical outcomes.

    Methods: We performed a retrospective review of patients treated at our institution for refractory PD who underwent bilateral STN DBS. The immediate post-operative CT was fused with the 4-week follow-up CT, and deviation of the electrode was determined. Amounts of ICA were calculated and correlated to various parameters. Patients were grouped according to amount of ICA, and clinical outcomes were assessed for each of these groups.

    Results: ICA had resolved fully at follow-up. In 60 total leads, average deviation at the tip was 1.14 ± 0.72 mm. The proximal lead deviated anteriorly an average of 2.97 ± 1.81 mm. Mean ICA was 20.7 ± 13.5 cm3, and did not significantly correlate to duration of disease, but did correlate to patient age and total number of passes (p < .05). There was a statistically significant correlation of ICA to proximal lead deviation (Pearson’s test, r=.356, p = .03), but not to tip deviation. Patients in group 4 with ICA greater than 30 cm3 had worse scores on the MDS-UPDRS part 3 at 6 and 12 months, while those with <30 cm3 had scores that were comparable and stable across time.

    Conclusions: Regardless of the amount of ICA introduced during surgery, electrode deviation at the tip is minimal. With ICA <30 cm3, there appears to be a negligible effect on clinical outcome scores, however, ICA greater than this may play a role in DBS success. Further studies with larger numbers of patients are needed to fully examine this.

    Patient Care: This research will improve patient care by helping elucidate the role of intracranial air in DBS electrode deviation and its clinical impact.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify factors that may lead to brain shift during stereotactic surgery, 2) Discuss the role of intracranial air on targeting accuracy, and 3) Discuss the effect of ICA on clinical outcome after DBS.

    References: 1. Azmi H, Machado A, Deogaonkar M, Rezai A. Intracranial Air Correlates with Preoperative Cerebral Atrophy and Stereotactic Error during Bilateral STN DBS Surgery for Parkinson's Disease. Stereotactic and Functional Neurosurgery. 2011;89:246-52. 2. Benabid AL, Chabardes S Fau - Mitrofanis J, Mitrofanis J Fau - Pollak P, Pollak P. Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson's disease. 3. Deuschl G, Schade-Brittinger C, Krack P, Volkmann J, Schafer H, Botzel K, et al. A randomized trial of deep-brain stimulation for Parkinson's disease. New England Journal of Medicine. 2006;355:896-908. 4. Elias WJ, Fu K-M, Frysinger RC. Cortical and subcortical brain shift during stereotactic procedures. Journal of Neurosurgery. 2007;107:983-88. 5. Khan MF, Mewes K, Gross RE, Skrinjar O. Assessment of brain shift related to deep brain stimulation surgery. Stereotactic and Functional Neurosurgery. 2008;86:44-53. 6. Kim HY, Chang WS, Kang DW, Sohn YH, Lee MS, Chang JW. Factors Related to Outcomes of Subthalamic Deep Brain Stimulation in Parkinson's Disease. Journal of Korean Neurosurgical Society. 2013;54:118-24. 7. Kim YH, Kim HJ, Kim C, Kim DG, Jeon BS, Paek SH. Comparison of electrode location between immediate postoperative day and 6 months after bilateral subthalamic nucleus deep brain stimulation. Acta Neurochirurgica. 2010;152:2037-45. 8. Miyagi Y, Shima F, Sasaki T. Brain shift: an error factor during implantation of deep brain stimulation electrodes. Journal of Neurosurgery. 2007;107:989-97. 9. Nimsky C, Ganslandt O, Cerny S, Hastreiter P, Greiner G, Fahlbusch R. Quantification of, visualization of, and compensation for brain shift using intraoperative magnetic resonance imaging. Neurosurgery. 2000;47:1070-79. 10. Paek SH, Lee JY, Kim HJ, Kang D, Lim YH, Kim MR, et al. Electrode Position and the Clinical Outcome after Bilateral Subthalamic Nucleus Stimulation. Journal of Korean Medical Science. 2011;26:1344-55. 11. Paek SH, Yun JY, Song SW, Kim IK, Hwang JH, Kim JW, et al. The clinical impact of precise electrode positioning in STN DBS on three-year outcomes. Journal of the Neurological Sciences. 2013;327:25-31. 12. Petersen EA, Holl EM, Martinez-Torres I, Foltynie T, Limousin P, Hariz MI, et al. Minimizing Brain Shift in Stereotactic Functional Neurosurgery. Neurosurgery. 2010;67:213-21.

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