Awake versus Asleep Anesthesia in Deep Brain Stimulation Surgery for Parkinson's Disease: A Systematic Review and Meta-Analysis

Abstract

Introduction: Deep brain stimulation (DBS) is a well-established surgical therapy for patients with Parkinsons' Disease (PD). Traditionally, DBS surgery for PD is performed under local anesthesia, whereby the patient is awake to facilitate intraoperative neurophysiological confirmation of the intended target using microelectrode recordings. General anesthesia allows for improved patient comfort without sacrificing anatomic precision and clinical outcomes.

Methods: We performed a systemic review and meta-analysis on patients undergoing DBS for PD. Published randomized controlled trials, prospective and retrospective studies, and case series which compared asleep and awake techniques for patients undergoing DBS for PD were included. A total of 19 studies and 1,900 patients were included in the analysis.

Results: We analyzed the (i) clinical effectiveness - postoperative UPDRS III score, levodopa equivalent daily doses and DBS stimulation requirements. (ii) Surgical and anesthesia related complications, number of lead insertions and operative time (iii) patient's quality of life, mood and cognitive measures using PDQ-39, MDRS, and MMSE scores. There was no significant difference in results between the awake and asleep groups, other than for operative time, for which there was significant heterogeneity.

Conclusion: With the advent of newer technology, there is likely to have narrowing differences in outcomes between awake or asleep DBS. What would therefore be more important would be to consider the patient's comfort and clinical status as well as the operative team's familiarity with the procedure to ensure seamless transition and care.

Keywords: Anesthesia; Central nervous system disease; Deep brain stimulation; Electric stimulation; Movement disorders; Parkinson disease.

Fig. 1.

Flowchart according to the PRISMA statement.

Fig. 2.

Risk of bias summary showing the risk of bias for each study. Green plus sign = low risk; red minus sign = high risk; yellow question mark = unclear risk.

Fig. 3.

Forest and funnel plots of between asleep and awake DBS surgery in studies evaluating postoperative UPDRS III score; postoperative LEDD and DBS stimulation requirements.

Fig. 4.

Forest plots of asleep and awake DBS surgery in studies evaluating surgical complications; anesthesia complications; number of lead insertions; operative time.

Fig. 5.

Forest plots of between asleep and awake DBS surgery in studies evaluating PDQ-39 scores; MDRS scores; MMSE scores.