Customized Anesthesia Approaches for Awake and Asleep DBS Implantation Using MER

Overview

Deep brain stimulation (DBS) implantation can be performed using awake or asleep anesthesia techniques, each with specific advantages and challenges. Awake procedures allow patient cooperation during microelectrode recordings (MER) for precise targeting, while asleep procedures improve patient comfort and have shown comparable clinical outcomes when anesthesia is carefully managed to preserve MER signals.

Background

DBS is an established treatment for advanced motor symptoms in neurodegenerative disorders such as Parkinson’s disease, essential tremor, and dystonia. The procedure involves stereotactic placement of electrodes into basal ganglia targets like the subthalamic nucleus (STN). Traditionally, DBS surgery is performed with the patient awake to enable intraoperative MER and symptom feedback, but asleep procedures under general anesthesia are increasingly preferred due to patient comfort and comparable efficacy. Anesthesia protocols must be optimized to balance sedation depth and the quality of MER signals.

Data Highlights

Patients aged 32 to 83 underwent bilateral STN-DBS implantation using either awake or asleep anesthesia protocols. All patients were in medication off state during surgery. Propofol and remifentanil infusions were titrated to achieve moderate sedation in awake patients and full general anesthesia with intubation in asleep patients. Nearly all patients received MER with up to five microelectrodes to guide lead placement. Surgical planning utilized MRI and CT imaging with stereotactic frames.

Key Findings

• Awake DBS procedures enable patient cooperation during MER, facilitating precise electrode targeting through symptom feedback.
• Awake surgery can be stressful and burdensome, requiring patients to be off medication and cooperative despite sedation effects.
• Asleep DBS procedures under general anesthesia improve patient comfort and have demonstrated clinical outcomes equivalent to awake procedures in multiple studies.
• MER quality can be affected by anesthetics; thus, anesthesia dosage must be carefully titrated during asleep procedures to preserve neuronal activity for recordings.
• Asleep-awake-asleep protocols allow temporary patient awakening for MER but may be limited by slow recovery from sedation.
• Customized anesthesia protocols at a high-volume center have enabled safe and effective DBS implantation using both awake and asleep approaches.

Clinical Implications

Clinicians should consider patient-specific factors such as age, general condition, and preference when selecting awake versus asleep DBS implantation. Careful anesthesia management is critical to maintain MER signal quality during asleep procedures. The availability of both approaches allows tailoring surgical plans to optimize patient comfort without compromising targeting accuracy or clinical outcomes.

Conclusion

Both awake and asleep anesthesia techniques for DBS implantation are feasible and effective when combined with appropriate MER protocols. Customized anesthesia approaches enable safe, precise electrode placement while balancing patient comfort and cooperation.

References

1. Article Source 2024 -- Anesthesia Techniques for Implanting Deep Brain Stimulation Systems