Advertisement

STN Stimulation in General Anaesthesia: Evidence Beyond ‘Evidence-Based Medicine’

  • Christian K. E. Moll
  • Sebastian Payer
  • Alessandro Gulberti
  • Andrew Sharrott
  • Simone Zittel
  • Kai Boelmans
  • Johannes Köppen
  • Christian Gerloff
  • Manfred Westphal
  • Andreas K. Engel
  • Christian Oehlwein
  • Carsten Buhmann
  • Wolfgang HamelEmail author
Conference paper
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 117)

Abstract

Awake surgery is regarded mandatory for optimal electrode implantation into the subthalamic nucleus (STN) for deep brain stimulation (DBS) in Parkinson’s disease (PD). However, this is questionable since general anaesthesia (GA) does not preclude intraoperative microrecordings and clinical evaluation of, for example, current spread to the corticospinal tract. In addition, even in the awake state, clinical testing is not without limitations. We report on intra- and postoperative findings in 11 patients suffering from advanced PD who were operated under GA (propofol/remifentanil). The activity of STN neurons under GA was characterized by excessive burst discharges that differed fundamentally from the irregular tonic patterns observed in the STN of awake patients. In all patients, we obtained improved motor symptoms and reduced levodopa-induced dyskinesias and motor fluctuations, which was associated with a reduction in the levodopa equivalent daily dose. Therapeutic DBS was not limited by current spread to the corticospinal tract in any of the patients. The trajectories chosen for electrode implantation in GA compared well to awake surgery. Our results indicate that STN surgery in GA can be performed in a safe manner. It can be offered to anxious patients, and represents a viable option when awake surgery bears a risk for the patient.

Keywords

Deep brain stimulation Subthalamic nucleus STN stimulation Parkinson’s disease General ­anaesthesia Microelectrode recordings 

Notes

Conflict of Interest

The authors have occasionally been reimbursed for travel expenses and received honoraria from Medtronic Inc. for speaking at meetings.

References

  1. 1.
    Chen SY, Tsai ST, Lin SH, Chen TY, Hung HY, Lee CW, Wang WH, Chen SP, Lin SZ (2011) Subthalamic deep brain stimulation in Parkinson’s disease under different anesthetic modalities: a comparative cohort study. Stereotact Funct Neurosurg 89:372–380PubMedCrossRefGoogle Scholar
  2. 2.
    Hamel W, Fietzek U, Morsnowski A, Schrader B, Herzog J, Weinert D, Pfister G, Muller D, Volkmann J, Deuschl G, Mehdorn HM (2003) Deep brain stimulation of the subthalamic nucleus in Parkinson’s disease: evaluation of active electrode contacts. J Neurol Neurosurg Psychiatry 74:1036–1046PubMedCrossRefGoogle Scholar
  3. 3.
    Harries AM, Kausar J, Roberts SA, Mocroft AP, Hodson JA, Pall HS, Mitchell RD (2011) Deep brain stimulation of the subthalamic nucleus for advanced Parkinson disease using general anesthesia: long-term results. J Neurosurg 116:107–113PubMedGoogle Scholar
  4. 4.
    Hertel F, Zuchner M, Weimar I, Gemmar P, Noll B, Bettag M, Decker C (2006) Implantation of electrodes for deep brain stimulation of the subthalamic nucleus in advanced Parkinson’s disease with the aid of intraoperative microrecording under general anesthesia. Neurosurgery 59:E1138; discussion E1138PubMedCrossRefGoogle Scholar
  5. 5.
    Lefaucheur JP, Gurruchaga JM, Pollin B, von Raison F, Mohsen N, Shin M, Menard-Lefaucheur I, Oshino S, Kishima H, Fenelon G, Remy P, Cesaro P, Gabriel I, Brugieres P, Keravel Y, Nguyen JP (2008) Outcome of bilateral subthalamic nucleus stimulation in the treatment of Parkinson’s disease: correlation with intra-operative multi-unit recordings but not with the type of anaesthesia. Eur Neurol 60:186–199PubMedCrossRefGoogle Scholar
  6. 6.
    Maltete D, Navarro S, Welter ML, Roche S, Bonnet AM, Houeto JL, Mesnage V, Pidoux B, Dormont D, Cornu P, Agid Y (2004) Subthalamic stimulation in Parkinson disease: with or without anesthesia? Arch Neurol 61:390–392PubMedCrossRefGoogle Scholar
  7. 7.
    Moll CK, Sharott A, Hamel W, Munchau A, Buhmann C, Hidding U, Zittel S, Westphal M, Muller D, Engel AK (2009) Waking up the brain: a case study of stimulation-induced wakeful unawareness during anaesthesia. Prog Brain Res 177:125–145PubMedCrossRefGoogle Scholar
  8. 8.
    Nakajima T, Zrinzo L, Foltynie T, Olmos IA, Taylor C, Hariz MI, Limousin P (2011) MRI-guided subthalamic nucleus deep brain stimulation without microelectrode recording: can we dispense with surgery under local anaesthesia? Stereotact Funct Neurosurg 89:318–325PubMedCrossRefGoogle Scholar
  9. 9.
    Patel NK, Plaha P, Gill SS (2007) Magnetic resonance imaging-directed method for functional neurosurgery using implantable guide tubes. Neurosurgery 61:358–365; discussion 365–356PubMedCrossRefGoogle Scholar
  10. 10.
    Starr PA, Martin AJ, Ostrem JL, Talke P, Levesque N, Larson PS (2010) Subthalamic nucleus deep brain stimulator placement using high-field interventional magnetic resonance imaging and a ­skull-mounted aiming device: technique and application accuracy. J Neurosurg 112:479–490PubMedCrossRefGoogle Scholar
  11. 11.
    Sutcliffe AJ, Mitchell RD, Gan YC, Mocroft AP, Nightingale P (2011) General anaesthesia for deep brain stimulator electrode insertion in Parkinson’s disease. Acta Neurochir (Wien) 153:621–627CrossRefGoogle Scholar
  12. 12.
    Yamada K, Goto S, Kuratsu J, Matsuzaki K, Tamura T, Nagahiro S, Murase N, Shimazu H, Kaji R (2007) Stereotactic surgery for subthalamic nucleus stimulation under general anesthesia: a retrospective evaluation of Japanese patients with Parkinson’s disease. Parkinsonism Relat Disord 13:101–107PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2013

Authors and Affiliations

  • Christian K. E. Moll
    • 1
  • Sebastian Payer
    • 2
  • Alessandro Gulberti
    • 1
  • Andrew Sharrott
    • 1
  • Simone Zittel
    • 3
  • Kai Boelmans
    • 3
  • Johannes Köppen
    • 2
  • Christian Gerloff
    • 3
  • Manfred Westphal
    • 2
  • Andreas K. Engel
    • 1
  • Christian Oehlwein
    • 4
  • Carsten Buhmann
    • 3
  • Wolfgang Hamel
    • 2
    Email author
  1. 1.Department of Neurophysiology and Pathophysiology, Center of Experimental MedicineUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Klinik für NeurochirurgieUniversitätsklinikum Hamburg-EppendorfHamburgGermany
  3. 3.Department of NeurologyUniversity Medical Center Hamburg-EppendorfHamburgGermany
  4. 4.Praxis für Neurologie und PsychiatrieGeraGermany

Personalised recommendations