Prevention and Treatment of Hardware-Related Infections in Deep Brain Stimulation Surgeries: A Retrospective and Historical Controlled Study

Abstract

Background: Hardware-related infection in deep brain stimulation (DBS) is one of the most commonly reported complications frequently resulting in the removal of implantable pulse generator (IPG).

Objective: The aim of this study was to establish a useful strategy to better prevent and treat those infections and to improve the preservation rates of IPG.

Methods: We conducted a retrospective and historical controlled study of all adult patients (≥18 years old) who had undergone initial DBS implantation at a single center. All participants were enrolled in the control group (between June 2005 and June 2014) or intervention group (between July 2014 and May 2019) based on their surgery dates. We used the intraoperative irrigation with hydrogen dioxide solution in the intervention group. Based on the dates of diagnosis, patients with hardware-related infection after DBS were enrolled in group A (between June 2005 and June 2014) or group B (between July 2014 and May 2019). IPG-sparing algorithm (Isa) was applied for group B. The early-onset IPG infections of the control and intervention groups were evaluated. The IPG preservation rates in both groups A and B were statistically analyzed.

Results: Six cases of early IPG infection and subsequent IPG removal occurred in the control group, while none occurred after intraoperative usage of the hydrogen dioxide in the intervention group. IPG preservation rate of infected cases in group B was significantly higher than that in group A (70% vs.16%, p = 0.004).

Conclusion: The combined application of hydrogen dioxide solution and Isa seems to be an effective strategy to prevent IPG infection.

Keywords: deep brain stimulation; hardware-related complication; implantable pulse generator; infection; treatment of infection.

FIGURE 1

Enrollment of patients and flow diagram. DBS, deep brain stimulation; IPG, implantable pulse generator; H₂O₂, 3% solution of hydrogen peroxide, which was used at the IPG pocket to prevent the early and primary IPG infection.

FIGURE 2

Hardware-related infections in group A (time interval to diagnosis of infection). Twenty-five cases of hardware-related infections were enrolled in group A (between June 2005 and June 2014) based on the date of diagnosis. Eight cases presented early-onset infection while 17 cases presented late-onset infection. IPG, implantable pulse generator.

FIGURE 3

Spreading of hardware-related infections in group A. *73: The infection arising from the left head spread to the right postauricular area 73 months post-diagnosis of infection. This patient underwent five times of local incision debridement (including two times of rotational flap) before intracranial lead removal. Months: Time interval of infections spreading from frontal to postauricular area counted by months. Weeks: Time interval of infections spreading from postauricular area to infraclavicular region (IPG pocket) counted by weeks. Six infections of frontal origin and seven infections of postauricular origin finally spread to IPG. Among a total of 22 IPG infections, 21 were removed, with only 1 IPG remaining at a place after being sterilized with ethylene oxide. The exposed parts of the hardware in the picture were taken from real photos. IPG, implantable pulse generator.

FIGURE 4

The safe time window for the application of Isa. Thirteen cases of infection spread to IPG in group A including six originating from frontal while seven originating from postauricular area. Seven cases of infection in group B underwent Isa within the safe time window. Months and days: The interval of infection spreading from frontal to postauricular area counted in months and subsequently to infraclavicular region (IPG pocket) counted in days. Significant difference in the interval duration was reported between two sections (Wilcoxon signed-rank test, p = 0.025). IPG, implantable pulse generator.

FIGURE 5

Hardware-related infections in group B (time interval to diagnosis of infection). Ten cases of hardware-related infections were enrolled in group B (between July 2014 and May 2019) based on the date of diagnosis. One case presented early-onset infection while nine cases presented late-onset infection. IPG, implantable pulse generator.