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The risk factors of intracerebral hemorrhage in deep brain stimulation: does target matter?

  • Original Article - Functional Neurosurgery - Movement disorders
  • Published:
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Abstract

Background

Although deep brain stimulation (DBS) is a relatively safe and effective surgery compared with ablative surgeries, intracerebral hemorrhage (ICH) is a serious complication during DBS that could result in a fatal prognosis. We retrospectively investigated whether ICH incidence differed between patients who underwent DBS in the subthalamic nucleus (STN) and in the globus pallidus interna (GPi), together with previously identified risk factors for ICH.

Methods

We retrospectively reviewed the medical records of 275 patients (527 DBS targets) who received DBS for Parkinson’s disease or dystonia from April 2001 to December 2020. In cases that developed intra- or postoperative ICH, patients were classified as asymptomatic, symptomatic with temporary neurological deficit or symptomatic with permanent neurological deficit, according to patient clinical status.

Results

ICH occurred in 12 procedures (2.3%) among the 527 DBS procedures (275 patients) evaluated. In multivariable logistic regression analysis, the risk factor for all cases of ICH was systolic blood pressure (BP) during surgery (cut-off value 129.4 mmHg) (OR = 1.05, 95% CI = 1.01–1.09, P = 0.023). In addition, for ICH with permanent neurological deficit, STN target site (P = 0.024) and systolic BP during surgery (cut-off value: 148.3 mmHg) (P = 0.004) were identified as risk factors in univariable analyses.

Conclusion

Even though the risk factor for all ICH in DBS was BP during surgery, when focused on ICH evoking permanent neurological deficit, the target location as well as systolic BP during surgery proved to be related.

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Abbreviations

AUC:

Area under the curve

BP:

Blood pressure

CI:

Confidence interval

DBS:

Deep brain stimulation

GPi:

Globus pallidus interna

HTN:

Hypertension

ICH:

Intracerebral hemorrhage

MRI:

Magnetic resonance imaging

MER:

Microelectrode recording

OR:

Odds ratio

ROC:

Receiver operating characteristic

STN:

Subthalamic nucleus

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Acknowledgements

No benefits in any form have been or will be received from a commercial party directly or indirectly related to the subject of this manuscript. The submitted manuscript does not contain information about medical device(s) or drug(s).

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Authors and Affiliations

  1. Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea

    Hong Kyung Shin, Hyung Ho Yoon & Sang Ryong Jeon

  2. Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

    Mi Sun Kim & Sun Ju Chung

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  1. Hong Kyung Shin
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Correspondence to Sang Ryong Jeon.

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Comments

Very nice paper retrospectively evaluating the risk of ICH after GPi or STN targeting for DBS against PD or Dystonia. The sample covers 20 years and includes 275 patients and 527 DBS implantations. All implantations are performed with neuronavigation and microelectrode recording, and all patients where postoperatively scanned within 6 h and the day after.

Thus, the calculated 2.3% risk of ICH pr DBS electrode placement is a reliable and well-justified number. Furthermore, it is interesting to note that of the 12 patients with ICH, only 5 had permanent neurological sequelae, and they had all received STN-implantation.

Carsten Reidies Bjarkam

Aalborg, Denmark

The authors of this paper analyzed their large institutional experience with DBS implantation and discovered significantly higher incidence of intracerebral hemorrhages in those patients who experienced elevated blood pressure during surgery (a very much expected finding) and those whose surgery was targeting STN compared to GPI (rather unexpected finding). Patients with multiple microelectrode recording (MER) passes had twice as high incidence of hemorrhages, but this difference did not reach statistical significance. Similarly, simultaneous bilateral surgery cases were twice as likely to be associated with hemorrhage compared to unilateral and staged bilateral interventions, and this difference was also not statistically significant. Since previous research strongly suggested correlation between the number of MER passes and incidence of hemorrhage, one would wonder if the observed difference between STN and GPI was in fact caused by a combination of higher number of MER tracks and single-stage bilateral surgery rather than the target location. Nevertheless, I feel that the diligent blood pressure control during DBS surgery is of paramount importance and has to be properly addressed by continuous monitoring and appropriate interventions.

Konstantin Slavin,

Chicago, Ill. USA

Hong Kyung Shin and Mi Sun Kim contributed equally to this work.

This article is part of the Topical Collection on Functional Neurosurgery - Movement disorders

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Shin, H.K., Kim, M.S., Yoon, H.H. et al. The risk factors of intracerebral hemorrhage in deep brain stimulation: does target matter?. Acta Neurochir 164, 587–598 (2022). https://doi.org/10.1007/s00701-021-04977-y

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  • DOI: https://doi.org/10.1007/s00701-021-04977-y

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