Asleep subthalamic deep brain stimulation for Parkinson's disease [Neurosurgery Wiki]

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====== Asleep subthalamic deep brain stimulation for Parkinson's disease ======

Recent advances in methods used for [[deep brain stimulation]] (DBS) include [[subthalamic nucleus]] electrode implantation in the "[[asleep]]" patient without the traditional use of [[microelectrode recording]]s or intraoperative test stimulation. 

===== Meta-Analysis =====

==== 2019 ====

Liu et al. systematically reviewed the [[literature]] to compare the [[efficacy]] and [[safety]] of [[awake]] and [[asleep deep brain stimulation]] surgery. They identified [[cohort]] studies from the [[Cochrane library]], [[MEDLINE]], and [[EMBASE]] (January 1970 to August 2019) by using [[Review Manager]] 5.3 software to conduct a [[meta-analysis]] following the [[PRISMA]] guidelines. Fourteen cohort studies involving 1,523 patients were included. The meta-analysis results showed that there were no significant differences between the GA and LA groups in [[UPDRS]]III score improvement (standard mean difference [SMD] 0.06; 95% CI -0.16 to 0.28; p = 0.60), postoperative LEDD requirement (SMD -0.17; 95% CI -0.44 to 0.12; p = 0.23), or operation time (SMD 0.18; 95% CI -0.31 to 0.67; p = 0.47). Additionally, there was no significant difference in the incidence of adverse events (OR 0.98; 95% CI 0.53-1.80; p = 0.94), including postoperative speech disturbance and intracranial hemorrhage. However, the volume of intracranial air was significantly lower in the GA group than that in the LA group. In a subgroup analysis, there was no significant difference in clinical efficacy between the [[microelectrode recording]] (MER) and non-MER groups. We demonstrated equivalent clinical outcomes of DBS surgery between GA and LA in terms of improvement of symptoms and the incidence of adverse events. Key Messages: MER might not be necessary for DBS implantation. For patients who cannot tolerate DBS surgery while being awake, GA should be an appropriate alternative
((Liu Z, He S, Li L. General Anesthesia versus Local Anesthesia for Deep Brain Stimulation in Parkinson's Disease: A Meta-Analysis. Stereotact Funct Neurosurg. 2019;97(5-6):381-390. doi:10.1159/000505079)).

===== Case series =====

A retrospective review of clinical outcomes of 152 consecutive patients. Their outcomes at 1 yr postimplantation are reported; these include Unified Parkinson's Disease Rating Scale ([[UPDRS]]) assessment, Mobility [[Tinetti Test]], [[PDQ-39]] quality of life assessment, [[Mattis Dementia Rating Scale]], [[Beck Depression Inventory]], and [[Beck Anxiety Inventory]]. They also report on a new parietal trajectory for electrode implantation.

[[UPDRS]] III improved from 39 to 20.5 (47%, P < .001). The total UPDRS score improved from 67.6 to 36.4 (46%, P < .001). UPDRS II scores improved from 18.9 to 10.5 (44%, P < .001) and UPDRS IV scores improved from 7.1 to 3.6 (49%, P < .001). There was a significant reduction in levodopa equivalent daily dose after surgery (mean: 35%, P < .001). [[PDQ-39]] summary index improved by a mean of 7.1 points. There was no significant difference found in clinical outcomes between the frontal and parietal approaches.

"Asleep" robot-assisted DBS of the subthalamic nucleus demonstrates comparable outcomes with traditional techniques in the treatment of Parkinson's disease.
((Moran CH, Pietrzyk M, Sarangmat N, Gerard CS, Barua N, Ashida R, Whone A, Szewczyk-Krolikowski K, Mooney L, Gill SS. Clinical Outcome of "Asleep" Deep Brain Stimulation for Parkinson's disease Using Robot-Assisted Delivery and Anatomic Targeting of the Subthalamic Nucleus: A Series of 152 Patients. Neurosurgery. 2020 Sep 28:nyaa367. doi: 10.1093/neuros/nyaa367. Epub ahead of print. PMID: 32985669.)).
----
The objective of a study of Senemmar et al. was to investigate whether [[asleep deep brain stimulation]] surgery of the [[subthalamic nucleus]] ([[STN]]) improves [[therapeutic window]] (TW) for both [[directional]] (dDBS) and [[omnidirectional]] (oDBS) stimulation in a large single-center population.

A total of 104 consecutive patients with [[Parkinson's disease]] (PD) undergoing STN-DBS surgery (80 asleep and 24 awake) were compared regarding TW, therapeutic [[threshold]], [[side effect]] threshold, [[improvement]] of Unified PD Rating Scale motor score ([[UPDRS]]-III) and degree of levodopa equivalent daily dose (LEDD) reduction.

Asleep DBS surgery led to significantly wider TW compared to [[awake surgery]] for both dDBS and oDBS. However, dDBS further increased TW compared to oDBS in the asleep group only and not in the awake group. Clinical efficacy in terms of UPDRS-III improvement and LEDD reduction did not differ between groups.

The [[study]] provides first [[evidence]] for improvement of therapeutic window by [[asleep surgery]] compared to [[awake surgery]], which can be strengthened further by dDBS. These results support the notion of preferring asleep over awake surgery but needs to be confirmed by [[prospective]] [[trial]]s
((Senemmar F, Hartmann CJ, Slotty PJ, Vesper J, Schnitzler A, Groiss SJ. Asleep Surgery May Improve the Therapeutic Window for Deep Brain Stimulation of the Subthalamic Nucleus [published online ahead of print, 2020 Jul 13]. Neuromodulation. 2020;10.1111/ner.13237. doi:10.1111/ner.13237)).
----
Clinical outcome studies have shown that "[[asleep]]" DBS [[lead]] [[placement]], performed using intraoperative imaging with stereotactic accuracy as the surgical endpoint, has motor outcomes comparable to traditional "[[awake]]" DBS using [[microelectrode recording]] (MER), but with shorter case times and improved speech fluency
((Mirzadeh Z, Chen T, Chapple KM, Lambert M, Karis JP, Dhall R, Ponce FA.
Procedural Variables Influencing Stereotactic Accuracy and Efficiency in Deep
Brain Stimulation Surgery. Oper Neurosurg (Hagerstown). 2018 Oct 18. doi:
10.1093/ons/opy291. [Epub ahead of print] PubMed PMID: 30339204.
)).
----
Ninety-six patients were retrospectively matched pairwise (48 asleep and 48 awake) and compared regarding improvement of Unified PD Rating Scale Motor Score (UPDRS-III), cognitive function, Levodopa-equivalent-daily-dose (LEDD), stimulation amplitudes, side effects, surgery duration, and complication rates. Routine testing took place at three months and one year postoperatively.

Results: Chronic DBS effects (UPDRS-III without medication and with stimulation on [OFF/ON]) significantly improved UPDRS-III only after awake surgery at three months and in both groups one year postoperatively. Acute effects (percentage UPDRS-III reduction after activation of stimulation) were also significantly better after awake surgery at three months but not at one year compared to asleep surgery. UPDRS-III subitems "freezing" and "speech" were significantly worse after asleep surgery at three months and one year, respectively. LEDD was significantly lower after awake surgery only one week postoperatively. The other measures did not differ between groups.

Overall motor function improved faster in the awake surgery group, but the difference ceased after one year. However, axial subitems were worse in the asleep surgery group suggesting that worsening of axial symptoms was risked improving overall motor function. Awake surgery still seems advantageous for STN-DBS in PD, although asleep surgery may be considered with lower threshold in patients not suitable for awake surgery
((Blasberg F, Wojtecki L, Elben S, Slotty PJ, Vesper J, Schnitzler A, Groiss
SJ. Comparison of Awake vs. [[Asleep Surgery]] for Subthalamic Deep Brain Stimulation
in Parkinson's Disease. Neuromodulation. 2018 Aug;21(6):541-547. doi:
10.1111/ner.12766. Epub 2018 Mar 13. PubMed PMID: 29532)).

===== References =====