Anti-Coagulation and Deep Brain Stimulation: Never the Twain Shall Meet?

Abstract

Deep brain stimulation (DBS) for movement disorders is usually performed in older patients who may be prone to vascular co-morbidities such as atrial fibrillation or valvular disease that may require anti-coagulation. This potentially increases the risk of peri-operative intra-cranial haemorrhage and thus anti-coagulation therapy is generally considered a contraindication for DBS implantation. Cessation of anti-coagulants has to be balanced with the risk of thrombosis or ischaemic complications and, to compound issues, there is a paucity of guidelines and consensus on the management of anti-coagulation in patients undergoing DBS. To date, we have performed DBS successfully in 4 patients on lifelong anti-coagulation, having carefully managed their anti-coagulation in the peri-operative period. One patient developed a moderate haematoma around the implantable pulse generator 2 days post-operatively that was treated conservatively. Otherwise no other adverse effects or haemorrhagic complications occurred. We therefore propose that DBS implantation in this group of patients is safe, provided strict observation of protocols and careful management of the anti-coagulation therapy are undertaken. We describe the indications for anti-coagulation and provide a guideline for therapy in such patients according to our experience.

Successful subthalamic stimulation after failed gamma-knife thalamotomy in the treatment of tremor-dominant Parkinson’s disease

“…In general, patients on life-long anti-platelet or anti--coagulation therapy due to atrial fibrillation or valvular heart disease are considered to be at high risk of developing perioperative intracranial haemorrhage, and are not offered a DBS procedure. Some reports have highlighted the strict perioperative management necessary for those who undergo a DBS procedure and are on anti-platelet therapy [2]. Our patient also had a positive cardiac history and had been on anti-platelet therapy for nearly 10 years.…”

Surgical Management of Parkinson's Disease in the Elderly

“…The available recommendations are similar to other surgeries, ie discontinuing these drugs prior to DBS surgery. 57 Regarding cardiac pacemakers, there is some weak evidence from small studies suggesting that both devices do not appear to interfere with each other. 58 FIG.…”

“…There are concerns about the use of anticoagulants and antiplatelet therapy, once there is paucity of studies that evaluated this issue. The available recommendations are similar to other surgeries, ie discontinuing these drugs prior to DBS surgery 57 . Regarding cardiac pacemakers, there is some weak evidence from small studies suggesting that both devices do not appear to interfere with each other 58 …”

Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment

“…Perioperative management is crucial for an elective procedure such as DBS. There is an increasing number of elderly patients with movement disorders or chronic pain syndromes who often suffer also from co-morbidities such as cardiovascular diseases which require lifelong antiplatelet or anticoagulation treatment [ 4 ].…”

“…In general, any form of chronic anticoagulation treatment has been considered a relative contraindication for DBS [ 4 , 11 ]. The question, however, arises whether an established therapy such as DBS can be denied to these groups of patients.…”