Hemorrhage Detection and Incidence during Magnetic Resonance-Guided Deep Brain Stimulator Implantations

Abstract

Background/Aims: Intraoperative magnetic resonance imaging (iMRI) is increasingly used to implant deep brain stimulator (DBS) electrodes. The approach has the advantages of a high targeting accuracy, minimization of brain penetrations, and allowance of implantation under general anesthesia. The hemorrhagic complications of iMRI-guided DBS implantation have not been studied in a large series. We report on the incidence and characteristics of hemorrhage during these procedures. Methods: Hemorrhage incidence was assessed in a series of 231 iMRI procedures (374 electrodes implanted). All patients had movement disorders and the subthalamic nucleus or the globus pallidus internus was typically targeted. Hemorrhage was detected with intra- or postoperative MRI or postoperative computed tomography. Hemorrhage was classified based on its point of origin and clinical impact. Results: Hemorrhage and symptomatic hemorrhage were detected during 2.4 and 1.1% of electrode implantations, respectively. The hemorrhage origin was subdural/subarachnoid (n = 3), subcortical (n = 5), or deep (n = 1). Factors that contributed to hemorrhage included unintentional crossing of a sulcus and resistance at the pial membrane, which produced cortical depression and a rebound hemorrhage. Delayed hemorrhage occurred in 2 patients and was attributed to premature reintroduction of anticoagulation therapy or air intrusion into the cranial cavity. Conclusions: Hemorrhage was readily apparent on intraoperative imaging, and hemorrhage rates for iMRI-guided DBS implantations were comparable to those for conventional implantation approaches.

Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment

“…Intracranial hemorrhage in patients with DBS and subsequent anticoagulation therapy was reported very rarely. In one patient, high-dose intravenous heparin was administered on the first postoperative day for acute myocardial infarction [ 25 ], and in two other patients, edoxaban was restarted already on day 5 and day 7 after surgery [ 20 , 33 ]. One of these patients also had a recurrent hemorrhage later.…”

“…Deep brain stimulation (DBS) with chronically implanted electrodes and implantable pulse generators (IPG) has become a common and widely accepted therapy for various movement disorders, chronic pain, and psychiatric disorders [ 14 , 17 , 19 , 22 ]. Intracranial hemorrhage has been considered the most serious complication of DBS resulting in prolonged hospitalization, additional surgery, or permanent disability [ 20 , 24 , 29 , 35 ]. While the frequency of asymptomatic hemorrhage ranges between 0.2 and 3.7%, symptomatic hemorrhage occurs in 0.0–1.6% of patients with an overall mortality of 0.0–0.7% [ 11 , 38 ].…”

Accuracy of Intraoperative Computed Tomography in Deep Brain Stimulation—A Prospective Noninferiority Study

“…Magnetic resonance imaging (MRI) is considered to be the gold standard to assess the electrode position after DBS implantation (2)(3)(4)(5)(6)(7)(8)(9). MRI offers detailed visualization of relevant brain structures.…”

Are Transventricular Approaches Associated With Increased Hemorrhage? A Comparative Study in a Series of 624 Deep Brain Stimulation Surgeries

“…2 However, side effects include surgery-related complications, infection, and hardware-related problems. [3][4][5] In particular, intracranial hemorrhages have been reported to occur in 0.2% to 10% of DBS surgeries [6][7][8][9] with an overall incidence of approximately 5%, with 1.9% being asymptomatic, 2.1% being symptomatic, and 1.1% resulting in permanent disability or death. 10 There is agreement on several measures to minimize the risk for intracranial bleeding during DBS surgery.…”