Saving the Exposed Deep Brain Stimulation Implant: A Comprehensive Review of Implant Extrusion and Reconstructive Options

Abstract

Introduction: Deep brain stimulation (DBS) for the treatment of Parkinson disease is susceptible to complications, such as hardware extrusion, most commonly at the scalp and chest. The authors describe their experience with the management of hardware extrusion and reconstruction with one of the largest single-institution experience and suggest an evidence-based treatment algorithm for the management of such cases. Methods: A retrospective review of hospital records was performed to identify patients who underwent DBS-related surgery and reconstruction from January 2015 to April 2020. Management of these patients involved culture-directed antibiotics, local wound debridement, various forms of reconstruction, and hardware removal when indicated. Results: Ninety-four patients with 131 DBS-related procedures were included. Twelve patients (12.8%) had hardware extrusion, of which 6 occurred primarily at the scalp and 6 occurred primarily at the chest. Primary closure of scalp wounds (odds ratio, 0.05 [0.004-0.71], P = 0.035) was negatively associated with treatment success. The type of reconstruction of chest wounds did not affect its success ( P = 0.58); however, none of them involved a new surgical bed, such as contralateral or hypochondrial placement. Conclusions: Hardware extrusion is a significant complication of DBS-related surgery. Management of extrusion at the scalp should involve the use of tensionfree, well-vascularized locoregional flaps as opposed to primary closure. Implantable pulse generator extrusions at the chest can be managed with both primary closure and repositioning in a new surgical bed. Extruded DBS implants may be salvaged with appropriate reconstructive considerations, and the authors suggest an evidence-based treatment algorithm.

Periosteal Turnover Flap for Coverage and Salvage of Exposed Deep Brain Stimulation Device

“…Yet, there is no agreement on the best course of action if there isn't an obvious infection. [6][7] Moreover, malnutrition is a common problem in this patient group, leading to cachexia and causing them to have thinner scalp flaps, which makes them more susceptible to implant exposure and renders reconstruction more challenging. This is mainly caused by insufficient amounts of healthy tissue and wound healing problems.…”

“…8 Once exposed, foreign materials are quickly colonized and covered by biofilm, even when there are no apparent signs of active infection such as purulent drainage. 7 Biofilm layer arguably triggers re-exposure after reconstruction; therefore, any coverage option should be well-vascularized and resistant to both infection and mechanical forces. 7 Any salvage attempt should be performed in a quick manner to avoid increased colonization and infection since these implants have a direct connection with intracranial structures.…”

“…7 Biofilm layer arguably triggers re-exposure after reconstruction; therefore, any coverage option should be well-vascularized and resistant to both infection and mechanical forces. 7 Any salvage attempt should be performed in a quick manner to avoid increased colonization and infection since these implants have a direct connection with intracranial structures. Purpouse: The primary objective of this study is to suggest the use of acellular dermal matrix through an osteoplastic flap and transnasal endoscopic treatment for the management of frontal mucoceles.…”

“…Debridement, hardware removal, and suitable reconstruction should be carried out if a gross infection is evident. Yet, there is no agreement on the best course of action if there isn’t an obvious infection 6–7 …”

“…Mineral graft hydroxyapatite is not toxic to the tissues and has osteoconductive properties; however, it is too brittle and is easily resorbed when cerebrospinal fluid or water is present. 6,7 Recently, various materials, including allogenic acellular dermal matrix, have been introduced for immediate burr hole defect reconstruction. 1,3 However, burr hole cover can be applied immediately, followed by burr hole surgery because the shape of burr hole cover should precisely fit the skull defect area.…”