Management of Referred Deep Brain Stimulation Failures

Abstract

Background: Since the Food and Drug Administration approved DBS, there has been a surge in the number of centers providing the procedure. There is currently no consensus regarding appropriate screening procedures, necessary training of individuals providing the therapy, the need for an interdisciplinary team, or guidelines for the management of complications. An increasing number of patients come to experienced DBS centers after unsatisfactory results from DBS surgery. An attempt is made herein to evaluate the reasons for DBS failure in a series of such patients and to make recommendations to improve overall DBS outcomes. Objective: To improve outcomes of deep brain stimulation (DBS) surgery by analyzing a series of patients who had suboptimal results from DBS. Methods: Forty-one consecutive patients complaining of suboptimal results from DBS surgery came to the University of Florida Movement Disorders Center, or to Beth Israel Movement Disorders Center, over a 24-month period. All patients had undergone implantation of DBS devices at outside medical centers. Each patient was evaluated by a movement disorders neurologist, and the complete medical record was reviewed. The DBS device for each patient was interrogated for adverse effects and programmed for maximal benefit. Postoperative imaging studies were evaluated whenever possible. Results: The average age of patients was 63.4 years (range, 49-84 years). The indication for surgery (by record review) included 9 patients with essential tremor, 31 with Parkinson disease, and 1 with dystonia. The diagnoses after referral examination included 5 with essential tremor, 26 with Parkinson disease, 3 with Parkinson disease and dementia, 1 with Parkinson disease and essential tremor, 1 with corticobasal degeneration, 1 with dystonia, 2 with multiple system atrophy, 1 with progressive supranuclear palsy, and 1 with myoclonus. Issues related to inadequate preoperative screening: Thirty (73%) of 41 patients saw a Author Affiliations are listed at the end of this article.

Asleep Deep Brain Stimulation Reduces Incidence of Intracranial Air during Electrode Implantation

“…Clinical outcomes of DBS are dependent on the accuracy of electrode placement; misplaced leads account for up to 46% of treatment failures [10], and deviations from target as small as 2 mm may have a significant impact on stimulation [11-13]. Among the factors affecting accuracy of electrode placement, considerable interest has been dedicated to brain shift secondary to accumulation of intracranial air introducing a stereotactic error during the implantation [14-20].…”

Thalamotomy as a Treatment Option for Tremor after Ineffective Deep Brain Stimulation

“…Complications can occur early, e.g. during implantation, or they can occur after some time, such as lead fracture [14,15], wire exposure, generator malfunction, or a malpositioned electrode or lead migration [16], all of which can result in loss of efficacy. However, in some instances, efficacy loss or tolerance cannot be explained [17,18], and there is currently no consensus regarding a treatment plan for such patients [19].…”

“…Failure of DBS therapy due to malpositioning of the electrode has previously been reported [16]. Malpositioning of more than 2 mm is an indicator of poor lead location, and repositioning has reportedly improved outcome [21].…”

“…Access to therapy is an important consideration and has been reported as a reason for failed DBS response [16]. Additionally, DBS stimulator programming time, reported as 18–36.2 h per patient per year, can also act as a barrier to effective treatment [38,39].…”

Rationale and Clinical Pearls for Primary Care Doctors Referring Patients for Deep Brain Stimulation

“…Some DBS patients, however, required complete lead replacement. Troubleshooting is therefore a critical aspect of the long-term management of DBS and has the potential to enhance outcomes [36]. …”