Asphyxia due to laryngeal spasm as a severe complication of awake deep brain stimulation for Parkinson’s disease: a case report

Abstract

BackgroundIn accordance with German neurosurgical and neurological consensus recommendations, lead placements for deep brain stimulation (DBS) in patients with Parkinson’s disease (PD) are usually performed with the patient awake and in “medication off” state. This allows for optimal lead position adjustment according to the clinical response to intraoperative test stimulation. However, exacerbation of Parkinsonian symptoms after withdrawal of dopaminergic medication may endanger the patient by inducing severe “off” state motor phenomena. In particular, this can be a problem in awake craniotomies utilizing intraoperative airway management and resuscitation.Case presentationWe report the case of a PD patient with progressive orofacial and neck muscle dystonia resulting in laryngeal spasm during DBS lead placement. This led to upper airway compromise and asphyxia, requiring resuscitation.ConclusionsLaryngeal spasms may occur as a rare “off” state motor complication in patients with PD. Other potential causes of intraoperative difficulties breathing include bilateral vocal cord palsy, positional asphyxia, and silent aspiration. In our practice, we have adjusted our medication regimen and now allow patients to receive their standard dopaminergic medication until the morning of surgery. Neurologists and neurosurgeons performing lead placement procedures for PD should be aware of this rare but unsafe condition to most optimized treatment.

Jaw-opening dystonia in Parkinson’s disease improved by FOslevodopa-foscarbidopa Continuous Subcutaneous (FOCS) infusion

“…JOD is a rare and refractory form of dystonia in Parkinson's syndrome that signi cantly impacts quality of life and can be life-threatening. [1,2,5] Previous studies have indicated improvement in JOD with botulinum toxin or DBS. [1,2] However, botulinum toxin could not completely eliminate JOD and its excessive effectiveness in muscle relaxation risks impairing the ability to eat.…”

Reply to the commentary. Risks and tasks of awake craniotomy under conscious sedation

“…Cricothyroidotomy was effective only in 40% of cases in the context of ventilation, whereas tracheotomy done by an experienced surgeon was more effective [12]. Respiratory insufficiency, even asystole, was reported by some authors, during AC [12,13]. Various factors can cause respiratory insufficiency, not only the sedative drugs, as commonly believed, but electrical stimulation, neurophysiological monitoring, aspiration, epilepsy with trismus and tongue biting with bleeding, severe comorbidities, obesity, other rear diseases, and medications [13,14] All the above aspects should be analysed individually for candidates for AC [15].…”

A Pragmatic Approach to the Perioperative Management of Parkinson’s Disease

“…Although uncommon, there are reports of postoperative laryngospasm and respiratory failure in PD. 31,32 Hence, there should be a low threshold to go for chest X-rays, arterial blood gas analysis, and chest physical therapy if PD patients show signs of respiratory abnormalities.…”