Asleep Surgery May Improve the Therapeutic Window for Deep Brain Stimulation of the Subthalamic Nucleus

Abstract

Objective The effect of anesthesia type in terms of asleep vs. awake deep brain stimulation (DBS) surgery on therapeutic window (TW) has not been investigated so far. The objective of the study was to investigate whether asleep DBS surgery of the subthalamic nucleus (STN) improves TW for both directional (dDBS) and omnidirectional (oDBS) stimulation in a large single‐center population. Materials and Methods A total of 104 consecutive patients with Parkinson's disease (PD) undergoing STN‐DBS surgery (80 asleep and 24 awake) were compared regarding TW, therapeutic threshold, side effect threshold, improvement of Unified PD Rating Scale motor score (UPDRS‐III) and degree of levodopa equivalent daily dose (LEDD) reduction. Results Asleep DBS surgery led to significantly wider TW compared to awake surgery for both dDBS and oDBS. However, dDBS further increased TW compared to oDBS in the asleep group only and not in the awake group. Clinical efficacy in terms of UPDRS‐III improvement and LEDD reduction did not differ between groups. Conclusions Our study provides first evidence for improvement of therapeutic window by asleep surgery compared to awake surgery, which can be strengthened further by dDBS. These results support the notion of preferring asleep over awake surgery but needs to be confirmed by prospective trials.

Anesthesia for deep brain stimulation system implantation: adapted protocol for awake and asleep surgery using microelectrode recordings

“…No anesthesia-related clinical issues were noted, and clinical outcomes in the asleep group were equivalent or better than those of the awake group. Recently, we could also show that our modified anesthesia protocol may increase therapeutic window compared to conventional awake surgery [ 31 ]. Together, this supports the safety and effectiveness of this approach.…”

“…Taking another approach, DBS implantations can also be completed in asleep patients, that is, under full general anesthesia. Clinical outcomes of awake and asleep lead placements have generally been equivalent [7,8,16,31,34,37], albeit with small sample sizes and high patient heterogeneity in some comparative trials. The equivalence of asleep procedures, together with the face validity of increased patient comfort, has led to a shifting of perspectives that makes asleep DBS procedures the preferred approach [6].…”

“…This approach may, however, see some patients who are slow to rouse from sedation or remain too groggy to participate in the MER feedback. Another option, described in a previous report from our group [ 4 , 31 ], is to induce full intubated general anesthesia and to temporarily reduce the anesthesia during the MER process to allow the observation of some indicators such as the appearance of discrete muscle twitching due to pyramidal tract stimulation.…”

Surgical Strategy for Directional Deep Brain Stimulation

“…Senemmar et al reported that asleep STN-DBS surgery led to a significantly wider TW than awake surgery for both DS and OS, with no difference in clinical effects between methods. 48) On the other hand, many reports have described DBS lead placement using only a neuroimaging guide, finding no difference in clinical effects from placement with MER guidance. 49 – 52) Although D-lead placement with only a neuroimaging guide has been reported 21) and the asleep STN-DBS surgery with D-lead is expected to increase in the future, no reports have examined indicators for lead placement or compared clinical effects.…”