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Fortmann T, Zawy Alsofy S, Lewitz M, Santacroce A, Welzel Saravia H, Sakellaropoulou I, Wilbers E, Grabowski S, Stroop R, Cinibulak Z, Nakamura M, Lehrke R. Rescuing Infected Deep Brain Stimulation Therapies in Severely Affected Patients. Brain Sci 2023; 13:1650. [PMID: 38137098 PMCID: PMC10742038 DOI: 10.3390/brainsci13121650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/02/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023] Open
Abstract
(1) Background: Infections in deep brain stimulation (DBS) hardware, while an undesired complication of DBS surgeries, can be effectively addressed. Minor infections are typically treated with wound revision and IV antibiotics. However, when visible hardware infection occurs, most centers opt for complete removal, leaving the patient in a preoperative state and necessitating post-removal care. To avoid the need for such care, a novel technique was developed. (2) Methods: The electrodes are placed at the exact same spot and then led to the contralateral side. new extensions and a new generator contralateral to the infection as well. Subsequently, the infected system is removed. This case series includes six patients. (3) Results: The average duration of DBS system implantation before the second surgery was 272 days. Only one system had to be removed after 18 months due to reoccurring infection; the others remained unaffected. Laboratory alterations and pathogens were identified in only half of the patients. (4) Conclusions: The described surgical technique proves to be safe, well tolerated, and serves as a viable alternative to complete system removal. Importantly, it effectively prevents the need of post-removal care for patients.
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Affiliation(s)
- Thomas Fortmann
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
- Department of Stereotactic Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
| | - Samer Zawy Alsofy
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
| | - Marc Lewitz
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
| | - Antonio Santacroce
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
- European Radiosurgery Center Munich, 81377 Munich, Germany
| | - Heinz Welzel Saravia
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
| | - Ioanna Sakellaropoulou
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
| | - Eike Wilbers
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
| | - Steffen Grabowski
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (H.W.S.); (I.S.); (S.G.)
| | - Ralf Stroop
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
| | - Zafer Cinibulak
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, Academic Hospital Koeln-Merheim, Witten/Herdecke University, 51109 Koeln, Germany
| | - Makoto Nakamura
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.Z.A.); (M.L.); (A.S.); (E.W.); (R.S.); (Z.C.); (M.N.)
- Department of Neurosurgery, Academic Hospital Koeln-Merheim, Witten/Herdecke University, 51109 Koeln, Germany
| | - Ralph Lehrke
- Department of Stereotactic Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
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Rich AM, Karakoleva EV, McInerney J, Farace E, De Jesus S. Cerebrotendinous xanthomatosis tremor successfully controlled post-ventral intermediate nucleus-deep brain stimulation: a case report. Front Neurol 2023; 14:1243379. [PMID: 37712087 PMCID: PMC10498991 DOI: 10.3389/fneur.2023.1243379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/07/2023] [Indexed: 09/16/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder caused by a deficiency of the sterol 27-hydroxylase enzyme. This deficiency results in excess production and accumulation of cholestanol, which can lead to many clinical findings within the first three decades of life, including progressive neurological dysfunction. This is a treatable condition with improvements in neurological and non-neurological symptoms upon the early initiation of replacement therapy. This case report details a 42 years-old left-handed male in whom deep brain stimulation (DBS) intervention was pursued due to a limiting tremor related to delayed diagnosis and treatment of CTX at 22 years old. The application of DBS in treating tremors in a CTX patient has not previously been reported. For our patient, application of DBS led to meaningful and longstanding tremor control benefits that have required minimal changes to stimulation parameters post-DBS. These improvements to tremor were achieved without negative impact to his other CTX related comorbidities.
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Affiliation(s)
- Alyson M. Rich
- Department of Neurology, Penn State College of Medicine, Hershey, PA, United States
| | - Ema V. Karakoleva
- Department of Neurology, Penn State College of Medicine, Hershey, PA, United States
| | - James McInerney
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, United States
| | - Elana Farace
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, United States
| | - Sol De Jesus
- Department of Neurology, Penn State College of Medicine, Hershey, PA, United States
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Evans AR, Grossen AA, Prather KY, Conner AK. Subsuperficial Pectoralis Fascial Placement of Implantable Pulse Generators in Deep Brain Stimulation Surgery: Technical Note. NEUROSURGERY OPEN 2023. [DOI: 10.1227/neuprac.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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Chen F, Meng X, Li T, Xu Z, Li S, Zhou Y, Hou X, Tan S, Mei L, Li L, Chang B, Wang W, Liu M. Predictive nomogram for deep brain stimulation-related infections. Neurosurg Focus 2022; 53:E8. [PMID: 36455280 DOI: 10.3171/2022.9.focus21558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Infection is one of the important and frequent complications following implantable pulse generator and deep brain stimulation (DBS) electrode insertion. The goal of this study was to retrospectively evaluate and identify potential risk factors for DBS infections. METHODS From January 2015 to January 2021 in Qingdao municipal hospital (training cohort) and The First Affiliated Hospital of the University of Science and Technology of China (validation cohort), the authors enrolled patients with Parkinson disease who had undergone primary DBS placement or implantable pulse generator replacement. The cases were divided into infection or no-infection groups according to the 6-month follow-up. The authors used the logistic regression models to determine the association between the variables and DBS infection. Depending on the results of logistic regression, the authors established a nomogram. The calibration curves, receiver operating characteristic curve analysis, and decision curves were used to evaluate the reliability of the nomogram. RESULTS There were 191 cases enrolled in the no-infection group and 20 cases in the infection group in the training cohort. The univariate logistic regression showed that BMI, blood glucose, and albumin were all significant predictors of infection after DBS surgery (OR 0.832 [p = 0.009], OR 1.735 [p < 0.001], and OR 0.823 [p = 0.001], respectively). In the crude, adjust I, and adjust II models, the three variables stated above were all considered to be significant predictors of infection after DBS surgery. The calibration curves in both training and validation cohorts showed that the predicted outcome fitted well to the observed outcome (p > 0.05). The decision curves showed that the nomogram had more benefits than the "All or None" scheme. The areas under the curve were 0.93 and 0.83 in the training and validation cohorts, respectively. CONCLUSIONS The nomogram included BMI, blood glucose, and albumin, which were significant predictors of infection in patients with DBS surgery. The nomogram was reliable for clinical application.
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Affiliation(s)
- Feng Chen
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Xiankun Meng
- 2Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, Shandong Province; and
| | - Tong Li
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Zhiming Xu
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Shengli Li
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Yong Zhou
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Xiaoqun Hou
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Shougang Tan
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Lin Mei
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Luo Li
- 2Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, Shandong Province; and
| | - Bowen Chang
- 3Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, Anhui Province, People's Republic of China
| | - Weimin Wang
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
| | - Mingxing Liu
- 1Department of Neurosurgery, Qingdao Municipal Hospital (Headquarters), Qingdao, Shandong Province
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Habibagahi I, Omidbeigi M, Hadaya J, Lyu H, Jang J, Ardell JL, Bari AA, Babakhani A. Vagus nerve stimulation using a miniaturized wirelessly powered stimulator in pigs. Sci Rep 2022; 12:8184. [PMID: 35581302 PMCID: PMC9114380 DOI: 10.1038/s41598-022-11850-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/26/2022] [Indexed: 11/09/2022] Open
Abstract
Neuromodulation of peripheral nerves has been clinically used for a wide range of indications. Wireless and batteryless stimulators offer important capabilities such as no need for reoperation, and extended life compared to their wired counterparts. However, there are challenging trade-offs between the device size and its operating range, which can limit their use. This study aimed to examine the functionality of newly designed wirelessly powered and controlled implants in vagus nerve stimulation for pigs. The implant used near field inductive coupling at 13.56 MHz industrial, scientific, and medical band to harvest power from an external coil. The circular implant had a diameter of 13 mm and weighed 483 mg with cuff electrodes. The efficiency of the inductive link and robustness to distance and misalignment were optimized. As a result, the specific absorption rate was orders of magnitude lower than the safety limit, and the stimulation can be performed using only 0.1 W of external power. For the first time, wireless and batteryless VNS with more than 5 cm operation range was demonstrated in pigs. A total of 84 vagus nerve stimulations (10 s each) have been performed in three adult pigs. In a quantitative comparison of the effectiveness of VNS devices, the efficiency of systems on reducing heart rate was similar in both conventional (75%) and wireless (78.5%) systems. The pulse width and frequency of the stimulation were swept on both systems, and the response for physiological markers was drawn. The results were easily reproducible, and methods used in this study can serve as a basis for future wirelessly powered implants.
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Affiliation(s)
- Iman Habibagahi
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA.
| | - Mahmoud Omidbeigi
- Department of Neurosurgery, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA.,Molecular, Cellular and Integrative Physiology Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Hongming Lyu
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA
| | - Jaeeun Jang
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Ausaf A Bari
- Department of Neurosurgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Aydin Babakhani
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA.
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Kondapavulur S, Burke J, Volz M, Wang DD, Starr PA. Use of Topical Vancomycin Powder to Reduce Surgical Site Infections after Deep Brain Stimulation Surgery: UCSF Experience and Meta-Analysis. Stereotact Funct Neurosurg 2022; 100:130-139. [PMID: 34839296 PMCID: PMC8917085 DOI: 10.1159/000520197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/17/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Surgical site infection (SSI) is the most common serious complication of deep brain stimulation (DBS) implantation surgery. Here, we report a single-surgeon experience on the efficacy of topical, intrawound vancomycin powder (VP) in reducing SSI for DBS surgery and present the first systematic review and meta-analysis examining the effect of topical vancomycin on SSI in patients after DBS surgery. METHODS For the retrospective review, all unique patients undergoing DBS surgery at UCSF for new hardware implantation or internal pulse generator (IPG) replacement by a single surgeon from September 2013 to March 2019, with at least 1 year of follow-up data, were included. For the meta-analysis, we included all primary studies that compared SSIs with and without application of topical vancomycin in DBS surgeries. RESULTS 368 unique patients met inclusion criteria; 195 patients received topical VP (VP group) and 173 did not (control). 99/195 patients in the VP group underwent new DBS implantation and 96/195 had IPG replacement. 71/173 patients in the control group had new DBS implantation and 102/173 had IPG replacement. There were 10 total cases of SSI: 4 patients from the VP group (3 new implants and 1 IPG replacement) and 6 patients from the control group (3 new implants and 3 IPG replacements), resulting in SSI rates of 2.1 and 3.5%, respectively (p value = 0.337). Including our retrospective analysis, 6 studies met inclusion criteria for the systematic review and meta-analysis. In the 4 studies that examined primary DBS implants, 479 total patients received topical VP and 436 did not; mean odds ratio for SSI with topical vancomycin was 0.802 (95% confidence interval [CI] 0.175-3.678). Across the 5 studies that examined IPG implantations or replacements, 606 total patients received topical VP while 1,173 patients did not; mean odds ratio for SSI with topical vancomycin was 0.492 (95% CI 0.164-1.475). In either case, topical VP application did not significantly decrease risk of SSI. CONCLUSION Surgical infections after DBS surgery are uncommon events, with studies demonstrating mixed results on whether topical vancomycin reduces this risk. Our single-institution retrospective analysis and systematic review of prior studies both demonstrated no significant SSI rate reduction with topical VP. This is likely due to low baseline SSI rates, resulting in a small effect size for prevention. Given the cost-effectiveness, simplicity, and low risk, topical, intrawound VP remains a treatment option to further reduce risk of SSI, particularly in settings with higher baseline infection rates.
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Affiliation(s)
| | - John Burke
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Monica Volz
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Doris D. Wang
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Philip A. Starr
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
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Li J, Zhang W, Mei S, Qiao L, Wang Y, Zhang X, Li J, Hu Y, Jia X, Zhang Y. Prevention and Treatment of Hardware-Related Infections in Deep Brain Stimulation Surgeries: A Retrospective and Historical Controlled Study. Front Hum Neurosci 2021; 15:707816. [PMID: 34512294 PMCID: PMC8427065 DOI: 10.3389/fnhum.2021.707816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background Hardware-related infection in deep brain stimulation (DBS) is one of the most commonly reported complications frequently resulting in the removal of implantable pulse generator (IPG). Objective The aim of this study was to establish a useful strategy to better prevent and treat those infections and to improve the preservation rates of IPG. Methods We conducted a retrospective and historical controlled study of all adult patients (≥18 years old) who had undergone initial DBS implantation at a single center. All participants were enrolled in the control group (between June 2005 and June 2014) or intervention group (between July 2014 and May 2019) based on their surgery dates. We used the intraoperative irrigation with hydrogen dioxide solution in the intervention group. Based on the dates of diagnosis, patients with hardware-related infection after DBS were enrolled in group A (between June 2005 and June 2014) or group B (between July 2014 and May 2019). IPG-sparing algorithm (Isa) was applied for group B. The early-onset IPG infections of the control and intervention groups were evaluated. The IPG preservation rates in both groups A and B were statistically analyzed. Results Six cases of early IPG infection and subsequent IPG removal occurred in the control group, while none occurred after intraoperative usage of the hydrogen dioxide in the intervention group. IPG preservation rate of infected cases in group B was significantly higher than that in group A (70% vs.16%, p = 0.004). Conclusion The combined application of hydrogen dioxide solution and Isa seems to be an effective strategy to prevent IPG infection.
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Affiliation(s)
- Jiping Li
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenjie Zhang
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shanshan Mei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liang Qiao
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yunpeng Wang
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianyu Li
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongsheng Hu
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaofei Jia
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuqing Zhang
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Spindler P, Faust K, Finger T, Schneider GH, Bayerl S, Trampuz A, Kühn AA, Vajkoczy P, Prinz V. High Frequency of Low-Virulent Microorganisms Detected by Sonication of Implanted Pulse Generators: So What? Stereotact Funct Neurosurg 2021; 100:8-13. [PMID: 34488223 DOI: 10.1159/000517472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/10/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) has become a well-established treatment modality for a variety of conditions over the last decades. Multiple surgeries are an essential part in the postoperative course of DBS patients if nonrechargeable implanted pulse generators (IPGs) are applied. So far, the rate of subclinical infections in this field is unknown. In this prospective cohort study, we used sonication to evaluate possible microbial colonization of IPGs from replacement surgery. METHODS All consecutive patients undergoing IPG replacement between May 1, 2019 and November 15, 2020 were evaluated. The removed hardware was investigated using sonication to detect biofilm-associated bacteria. Demographic and clinical data were analyzed. RESULTS A total of 71 patients with a mean (±SD) of 64.5 ± 15.3 years were evaluated. In 23 of these (i.e., 32.4%) patients, a positive sonication culture was found. In total, 25 microorganisms were detected. The most common isolated microorganisms were Cutibacterium acnes (formerly known as Propionibacterium acnes) (68%) and coagulase-negative Staphylococci (28%). Within the follow-up period (5.2 ± 4.3 months), none of the patients developed a clinical manifest infection. DISCUSSIONS/CONCLUSIONS Bacterial colonization of IPGs without clinical signs of infection is common but does not lead to manifest infection. Further larger studies are warranted to clarify the impact of low-virulent pathogens in clinically asymptomatic patients.
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Affiliation(s)
- Philipp Spindler
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Tobias Finger
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Simon Bayerl
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology, Movement Disorder and Neuromodulation Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
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9
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Ginalis EE, Hargreaves EL, Caputo DL, Danish SF. Is It Possible to Save the Deep Brain Stimulation Hardware when Presenting with Wound Dehiscence or Hardware Infection? Stereotact Funct Neurosurg 2021; 99:496-505. [PMID: 34289473 DOI: 10.1159/000517299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) hardware complications have been traditionally managed by removal of the entire system. Explantation of the system results in prolonged interruption to the patient's care and potential challenges when considering reimplantation of the cranial leads. The purpose of this study was to understand whether complete explantation can be avoided for patients initially presenting with wound dehiscence and/or infection of hardware. METHODS We performed a retrospective study that included 30 cases of wound dehiscence or infection involving the DBS system. Patients underwent reoperation without explantation of the DBS system, with partial explanation, or with complete explantation as initial management of the complication. RESULTS A total of 17/30 cases were managed with hardware-sparing wound revisions. The majority presented with wound dehiscence (94%), with the scalp (n = 9) as the most common location. This was successful in 76.5% of patients (n = 13). Over 11/30 patients were managed with partial explantation. The complication was located at the generator (91%) or at the scalp (9%). Partial explantation was successful in 64% of patients (n = 7). In cases that underwent a lead-sparing approach, 33% of patients ultimately required removal of the intracranial lead, and 2/30 cases of hardware infection were managed initially with total explantation. DISCUSSION/CONCLUSION Wound dehiscence can be successfully managed without complete removal of the DBS system in most cases. In cases of infection, removing the involved component(s) and sparing the intracranial leads may be considered. Wound revision without removal of the entire DBS system is safe and can improve quality of life by preventing or shortening the withdrawal of DBS treatment.
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Affiliation(s)
- Elizabeth E Ginalis
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA,
| | - Eric L Hargreaves
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.,Department of Neurology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Deborah L Caputo
- Department of Neurology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Shabbar F Danish
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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10
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Mostofi A, Baig F, Bourlogiannis F, Uberti M, Morgante F, Pereira EAC. Postoperative Externalization of Deep Brain Stimulation Leads Does Not Increase Infection Risk. Neuromodulation 2020; 24:265-271. [PMID: 33301223 DOI: 10.1111/ner.13331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/25/2020] [Accepted: 11/17/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Externalization of deep brain stimulation (DBS) leads is performed to allow electrophysiological recording from implanted electrodes as well as assessment of clinical response to trial stimulation before implantable pulse generator (IPG) insertion. Hypothetically, lead externalization provides a route for inoculation and subsequent infection of hardware, though this has not been established definitively in the literature. We sought to determine if lead externalization affects the risk of infection in DBS surgery. MATERIALS AND METHODS We present our center's experience of lead externalization and surgical site infection (SSI) in DBS surgery for movement disorders. Patients were divided into two cohorts: one in which leads were not externalized and IPGs were implanted at the time of electrode insertion, and one in which leads were externalized for six days while patients underwent electrophysiological recording from DBS electrodes for research. We compare baseline characteristics of these two cohorts and their SSI rates. RESULTS Infective complications were experienced by 3/82 (3.7%) patients overall with one (1.2%) requiring complete hardware removal. These occurred in 1/36 (2.7%) in the externalized cohort and 2/46 (4.3%) in the nonexternalized cohort. The incidence of infection between the two cohorts was not significantly different (p = 1, two-tailed Fisher's exact test). This lack of significant difference persisted when baseline variation between the cohorts in age, hardware manufacturer, and indication for DBS were corrected by excluding patients implanted for dystonia, none of whom underwent externalization. We present and discuss in detail each of the three cases of infection. CONCLUSIONS Our data suggest that externalization of leads does not increase the risk of infective complications in DBS surgery. Lead externalization is a safe procedure which can provide a substrate for unique neurophysiological studies to advance knowledge and therapy of disorders treated with DBS.
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Affiliation(s)
- Abteen Mostofi
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Neurosurgery, Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, UK
| | - Fahd Baig
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Medical Research Council Brain Network Dynamics Unit, Oxford, UK
| | - Fotios Bourlogiannis
- Department of Neurosurgery, Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, UK
| | - Micaela Uberti
- Department of Neurosurgery, Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, UK
| | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Erlick A C Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Neurosurgery, Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, UK
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Yu K, Niu X, He B. Neuromodulation Management of Chronic Neuropathic Pain in The Central Nervous system. ADVANCED FUNCTIONAL MATERIALS 2020; 30:1908999. [PMID: 34335132 PMCID: PMC8323399 DOI: 10.1002/adfm.201908999] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 05/05/2023]
Abstract
Neuromodulation is becoming one of the clinical tools for treating chronic neuropathic pain by transmitting controlled physical energy to the pre-identified neural targets in the central nervous system. Its nature of drug-free, non-addictive and improved targeting have attracted increasing attention among neuroscience research and clinical practices. This article provides a brief overview of the neuropathic pain and pharmacological routines for treatment, summarizes both the invasive and non-invasive neuromodulation modalities for pain management, and highlights an emerging brain stimulation technology, transcranial focused ultrasound (tFUS) with a focus on ultrasound transducer devices and the achieved neuromodulation effects and applications on pain management. Practical considerations of spatial guidance for tFUS are discussed for clinical applications. The safety of transcranial ultrasound neuromodulation and its future prospectives on pain management are also discussed.
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Affiliation(s)
| | | | - Bin He
- Department of Biomedical Engineering, Carnegie Mellon University
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12
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Atchley TJ, Elsayed GA, Sowers B, Walker HC, Chagoya G, Davis MC, Bernstock JD, Omar NB, Patel DM, Guthrie BL. Incidence and risk factors for seizures associated with deep brain stimulation surgery. J Neurosurg 2020; 135:279-283. [PMID: 32764176 DOI: 10.3171/2020.5.jns20125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine the incidence of seizures following deep brain stimulation (DBS) electrode implantation and to evaluate factors associated with postoperative seizures. METHODS The authors performed a single-center retrospective case-control study. The outcome of interest was seizure associated with DBS implantation. Univariate analyses were performed using the Student t-test for parametric continuous outcomes. The authors used the Kruskal-Wallis test or Wilcoxon rank-sum test for nonparametric continuous outcomes, chi-square statistics for categorical outcomes, and multivariate logistic regression for binomial variables. RESULTS A total of 814 DBS electrode implantations were performed in 645 patients (478 [58.7%] in men and 520 [63.9%] in patients with Parkinson's disease). In total, 22 (3.4%) patients who had undergone 23 (2.8%) placements experienced seizure. Of the 23 DBS implantation-related seizures, 21 were new-onset seizures (3.3% of 645 patients) and 2 were recurrence or worsening of a prior seizure disorder. Among the 23 cases with postimplantation-related seizure, epilepsy developed in 4 (17.4%) postoperatively; the risk of DBS-associated epilepsy was 0.50% per DBS electrode placement and 0.63% per patient. Nine (39.1%) implantation-related seizures had associated postoperative radiographic abnormalities. Multivariate analyses suggested that age at surgery conferred a modest increased risk for postoperative seizures (OR 1.06, 95% CI 1.02-1.10). Sex, primary diagnosis, electrode location and sidedness, and the number of trajectories were not significantly associated with seizures after DBS surgery. CONCLUSIONS Seizures associated with DBS electrode placement are uncommon, typically occur early within the postoperative period, and seldom lead to epilepsy. This study suggests that patient characteristics, such as age, may play a greater role than perioperative variables in determining seizure risk. Multiinstitutional studies may help better define and mitigate the risk of seizures after DBS surgery.
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Affiliation(s)
| | | | - Blake Sowers
- 2University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; and
| | | | | | | | - Joshua D Bernstock
- 4Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Introduction: Deep brain stimulation has emerged as an effective treatment for movement disorders such as Parkinson’s disease, dystonia, and essential tremor with estimates of >100,000 deep brain stimulators (DBSs) implanted worldwide since 1980s. Infections rates vary widely in the literature with rates as high as 25%. Traditional management of infection after deep brain stimulation is systemic antibiotic therapy with wound incision and debridement (I&D) and removal of implanted DBS hardware. The aim of this study is to evaluate the infections occurring after DBS placement and implantable generator (IPG) placement in order to better prevent and manage these infections. Materials/Methods: We conducted a retrospective review of 203 patients who underwent implantation of a DBS at a single institution. For initial electrode placement, patients underwent either unilateral or bilateral electrode placement with implantation of the IPG at the same surgery and IPG replacements occurred as necessary. For patients with unilateral electrodes, repeat surgery for placement of contralateral electrode was performed when desired. Preoperative preparation with ethyl alcohol occurred in all patients while use of intra-operative vancomycin powder was surgeon dependent. All patients received 24 hours of postoperative antibiotics. Primary endpoint was surgical wound infection or brain abscess located near the surgically implanted DBS leads. Infections were classified as early (<90 days) or late (>90 days). Infectious organisms were recorded based on intra-operative wound cultures. Number of lead implantations, IPG replacements and choice of presurgical, intra-operative, and postsurgical antibiotics were recorded and outcomes compared. Results: Two hundred and three patients underwent 391 electrode insertions and 244 IPG replacements. Fourteen patients developed an infection (10 early versus 4 late); 12 after implantation surgery (3%) and 2 after IPG replacement surgery (0.8%). No intracranial abscesses were found. Most common sites were the chest and connector. Staphylococcus aureus (MSSA) was the most common organism. Intra-operative vancomycin powder did not decrease infection risk. Vancomycin powder use was shown to increase risk of infection after electrode implantation surgery (Relative Risk 5.5080, p = 0.02063). Complete hardware removal occurred in eight patients, one patient had electrode only removal, three patients with I&D and no removal of hardware, and two patients with removal of IPG and extensor cables only. All patients were treated with postoperative intravenous antibiotics and no recurrent infections were found in patients with hardware left in place. Discussion/Conclusion: Infections after DBS implantation and IPG replacement occurred in 3% and 0.8% of patients respectively in our study which is lower than reported historically. Early infections were more common. No intracranial infections were found. Intra-operative use of vancomycin was not shown to decrease risk of infection after electrode implantation surgery or IPG replacement. However, in our study it was shown to increase risk of infection after electrode implantation surgery. Treatment includes antibiotic therapy and debridement with or without removal of hardware. DBS hardware can be safely left in place in select patients who may have significant adverse effects if it is removed.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Kevin Ray
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Ajay Ananda
- Neurosurgery, Kaiser Permanente, Los Angeles, USA
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