Clinical Scorecard: Anesthesia Techniques for Implanting Deep Brain Stimulation Systems: Customized Approaches for Awake and Sleep Surgery Utilizing Microelectrode Recordings

At a Glance

Key Highlights

• DBS electrodes are placed using stereotactic coordinates supplemented by preoperative imaging and intraoperative microelectrode recordings (MER).
• Awake DBS procedures allow patient cooperation for symptom feedback but can be stressful and require medication off state; asleep procedures under general anesthesia improve comfort.
• Asleep DBS procedures can incorporate MER by titrating anesthesia or using asleep-awake-asleep protocols to balance patient comfort and targeting precision.

Guideline-Based Recommendations

Diagnosis

• Confirm advanced motor symptoms of Parkinson’s disease or related disorders suitable for DBS.
• Use preoperative MRI and CT imaging for stereotactic planning targeting STN, GPi, or VIM.

Management

• Discontinue dopaminergic medications at least 12 hours before surgery, except subcutaneous apomorphine discontinued the morning of surgery.
• Choose awake or asleep DBS procedure based on multidisciplinary team assessment including patient preference, age, and general condition.
• Use propofol and remifentanil infusions to achieve moderate sedation for awake procedures or general anesthesia with intubation for asleep procedures.
• Employ microelectrode recordings intraoperatively to optimize lead placement; adjust anesthesia to allow MER signals.

Monitoring & Follow-up

• Monitor patient cooperation and symptom feedback during awake MER.
• In asleep procedures, monitor neuronal activity and consider temporary anesthesia reduction to observe indicators like muscle twitching.
• Ensure continuous anesthetic titration to balance sedation depth and MER quality.

Risks

• Awake procedures may cause patient stress and prolonged surgery duration.
• Anesthesia may suppress neuronal activity, potentially reducing MER precision in asleep procedures.
• Patient cooperation may be limited by sedation effects during awake or asleep-awake-asleep protocols.

Patient & Prescribing Data

Adults undergoing de novo bilateral STN-DBS implantation for Parkinson’s disease

Anesthesia protocols using propofol and remifentanil can be customized to allow effective MER during awake or asleep DBS surgery, optimizing clinical outcomes and patient comfort.

Clinical Best Practices

• Perform DBS surgery in medication off state with appropriate discontinuation of dopaminergic drugs.
• Use multidisciplinary team decision-making including patient and family input to select awake versus asleep procedure.
• Apply stereotactic planning with MRI and CT imaging combined with MER to enhance targeting accuracy.
• Carefully titrate anesthesia to maintain sufficient brain activity for MER while ensuring patient safety and comfort.
• Consider asleep-awake-asleep protocols or anesthesia reduction during MER to balance patient cooperation and recording quality.

References

• Abbott Infinity DBS System
• Study Registration 2,019,095,251