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The impact of brain shift in deep brain stimulation surgery: observation and obviation

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Abstract

Background

The impact of brain shift on deep brain stimulation surgery is considerable. In DBS surgery, brain shift is mainly caused by CSF loss. CSF loss can be estimated by post-surgical intracranial air. Different approaches and techniques exist to minimize CSF loss and hence brain shift. The aim of this survey was to investigate the extent and dynamics of CSF loss during DBS surgery, analyze its impact on final electrode position, and describe a simple and inexpensive method of burr hole closure.

Methods

Sixty-six patients being treated with deep brain stimulation were retrospectively analyzed for this treatise. During surgery, CSF loss was minimized using bone wax as a burr hole closure. Intracranial air volume was calculated based on early post-surgery stereotactic 3D CT and correlated with duration of surgery and electrode deviations derived from post-surgery image fusion.

Results

Median early post-surgery intracranial air was 2.1 cm3 (range 0–35.7 cm3, SD 8.53 cm3). No correlation was found between duration of surgery and CSF-loss (R = 0.078, p = 0.534), indicating that CSF loss mainly occurs early during surgery. Linear regression analysis revealed no significant correlations regarding volume of intracranial air and electrode displacement in any of the three principal axes. No significant difference regarding electrode deviations between first and second side of surgery were observed.

Conclusions

CSF loss mainly occurs during the early phase of DBS surgery. CSF loss during a later phase of surgery can be effectively averted by burr hole closure. Postoperative intracranial air volumes up to 35 cm3 did not result in significant electrode displacement in our series. Comparing our results to studies previously published on this subject, burr hole closure using bone wax is highly effective.

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Abbreviations

DBS:

Deep brain stimulation

MER:

Microelectrode recording

CSF:

Cerebrospinal fluid

SD:

Standard deviation

PD:

Parkinson’s disease

AC:

Anterior commissure

PC:

Posterior commissure

STN:

Subthalamic nucleus

SNr:

Substantia nigra pars reticulate

VIM:

Ventro intermediate nucleus of the thalamus

GPi:

Globus pallidus pars interna

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Acknowledgments

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Authors and Affiliations

  1. Neurochirurgische Klinik, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany

    P. J. Slotty, M. A. Kamp, C. Wille, T. M. Kinfe, H. J. Steiger & J. Vesper

Authors
  1. P. J. Slotty
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  2. M. A. Kamp
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  3. C. Wille
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  4. T. M. Kinfe
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  5. H. J. Steiger
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  6. J. Vesper
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Corresponding author

Correspondence to P. J. Slotty.

Additional information

Comment

The study by Slotty and colleagues must be commended for some of the information provided. Although other studies on the topic are available, the authors correctly measured the shift of the target points instead of using surrogate measures such as the shift of the intercommisural line. The authors demonstrate that the shift was clinically irrelevant. Brain shift due to CSF loss has early been recognized as an important source of error in deep brain stimulation surgery. Even though a negative effect on the precision of the procedure is undeniable, its real clinical importance is, in my opinion, relative. This is demonstrated by the high rate of efficacy of deep brain stimulation (DBS) for movement disorders with failures mainly ascribable to errors in patients' selection. With the current technique, it is possible to quickly insert cannulas along the selected trajectory immediately after a burr hole has been performed. Cannulas that serve to guide the microelectrode rigidly fix the brain, at least in the zone close to the target. More importantly, minimal shift due to CSF leakage are easily and reliably corrected using microelectrode recordings. This is an invaluable tool in confirming the target. This technique has contributed to the dramatic improvements that many patients have experienced with a wide array of stereotactic procedures. Nevertheless, postoperative pneumocephalus is a possible troubling complication of bilateral and long-lasting procedure such as DBS. Using burr hole sealants is a smart solution to avoid excessive CSF loss.

Alfredo Conti, ITALY

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Slotty, P.J., Kamp, M.A., Wille, C. et al. The impact of brain shift in deep brain stimulation surgery: observation and obviation. Acta Neurochir 154, 2063–2068 (2012). https://doi.org/10.1007/s00701-012-1478-y

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  • DOI: https://doi.org/10.1007/s00701-012-1478-y

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