Bilateral Subthalamic Nucleus Deep Brain Stimulation under General Anesthesia: Literature Review and Single Center Experience

Abstract

Bilateral subthalamic nucleus (STN) Deep brain stimulation (DBS) is a well-established treatment in patients with Parkinson's disease (PD). Traditionally, STN DBS for PD is performed by using microelectrode recording (MER) and/or intraoperative macrostimulation under local anesthesia (LA). However, many patients cannot tolerate the long operation time under LA without medication. In addition, it cannot be even be performed on PD patients with poor physical and neurological condition. Recently, it has been reported that STN DBS under general anesthesia (GA) can be successfully performed due to the feasible MER under GA, as well as the technical advancement in direct targeting and intraoperative imaging. The authors reviewed the previously published literature on STN DBS under GA using intraoperative imaging and MER, focused on discussing the technique, clinical outcome, and the complication, as well as introducing our single-center experience. Based on the reports of previously published studies and ours, GA did not interfere with the MER signal from STN. STN DBS under GA without intraoperative stimulation shows similar or better clinical outcome without any additional complication compared to STN DBS under LA. Long-term follow-up with a large number of the patients would be necessary to validate the safety and efficacy of STN DBS under GA.

Keywords: Parkinson’s disease; deep brain stimulation; general anesthesia; intraoperative computed tomography; intraoperative magnetic resonance imaging; local anesthesia; microelectrode recording; subthalamic nucleus.

Figure 1

Comparison of clinical outcomes between baseline and 6 months after STN Deep brain stimulation (DBS) under local anesthesia (LA) and general anesthesia (GA) each cohort. (A) Total Unified Parkinson’s Disease Rating Scale (UPDRS) and (B) UPDRS part III showed significant improvement after 6 months compared to baseline, except for LA cohort medication on state, there was no statistically significant difference between LA and GA cohort. (C) Hoehn & Yahr stage and (D) Schwab & England activities of daily living (ADL) showed no significant change in the medication on state in both LA and GA cohort, and no significant difference between two cohorts. (E) Dyskinesia disability and (F) Levodopa equivalent daily dose (LEDD) were significantly decreased in both LA and GA cohort. Only LEDD showed a significant difference in the change between LA and GA cohort. (G) Mini Mental State Examination (MMSE) and (H) Beck’s Depression Inventory (BDI), showed no statistically significant decrease in both LA and GA cohort. (I) Short form -36 (SF-36) physical health and (J) Short form -36 (SF-36) mental health showed no statistically significant increase in both LA and GA cohort.

Figure 2

Plotting of the electrode location based on the plotted position of the electrode in the axial view which is 3.5 mm below the anterior commissure (AC)–posterior commissure (PC) line in the human brain atlas of Schaltenbrand and Wahren. (A) Local anesthesia (LA) cohort, (B) General anesthesia (GA) cohort. Compared to LA cohort, the GA cohort showed a higher tendency for the electrode to be located within the subthalamic nucleus (STN).