Awake versus asleep deep brain stimulation for Parkinson's disease: a comprehensive systematic review and meta-analysis.

OBJECTIVE: Deep brain stimulation (DBS) has become an effective and safe treatment in patients with Parkinson's disease (PD) not responding to conventional treatments. With the growing body of literature regarding the use of DBS in different movement disorders, there remain controversies regarding performing awake or asleep DBS. This systematic review provides the most comprehensive review of the literature comparing the two techniques from various aspects in detail. METHODS: A systematic review of the PubMed, Scopus, Web of Science, and Cochrane Library databases was conducted. All studies comparing any aspects of asleep and awake DBS were included. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions tool. Meta-analysis was conducted with consideration of baseline characteristics. RESULTS: Thirty-one studies with 2563 PD patients were included. A total of 1423 patients underwent asleep DBS. The two groups were comparable regarding their baseline characteristics. The follow-up ranged from 3 to 60 months. The two DBS techniques were comparable in terms of motor symptom improvements and levodopa equivalent daily doses. However, the asleep technique showed slightly better improvements in Mattis Dementia Rating Scale and Parkinson's Disease Questionnaire scores. Moreover, the asleep technique was associated with more surgical adverse events, whereas pneumocephalus and psychological disorders such as mood, affect, and cognitive disorders were more common in the awake technique. Subgroup analyses revealed no significant differences in outcomes between asleep and awake DBS when categorized by targeted brain nuclei, use of intraoperative or preoperative imaging, and whether microelectrode recordings were used. CONCLUSIONS: These findings suggest comparable clinical outcomes between the two DBS approaches. The two methods had their salient differences in terms of lead passes and specific adverse events. The decision to perform awake or asleep DBS should be based on the patient's preference, the surgeon's experience, the availability of advanced intraoperative imaging, and the patient's tolerance for specific adverse events.

Evaluation of advanced emergency braking systems in drowsy driving-related real-world truck collisions.

STUDY OBJECTIVES: The effectiveness of advanced emergency braking systems (AEBS) in preventing drowsy driving-related truck collisions remains unclear. We aimed to evaluate the damage-mitigation effect of AEBS on drowsy driving-related collisions involving large trucks using collision rate and damage amount. METHODS: Data collected by a Japanese transportation company from 1,699 collisions involving 31,107 large trucks over 7 years were analyzed post-hoc. The collision rate (number of trucks with collisions/total number of trucks) and damage amount (total amount of property damage and personal injury) were compared based on whether the collisions were caused by drowsy or non-drowsy driving and whether the trucks were equipped with AEBS or not. RESULTS: For all and non-drowsy driving-related collisions, the collision rate for the 12,887 trucks with AEBS (1.62 and 1.20 collisions/truck/7 years, respectively) was significantly lower than that for the 18,220 trucks without AEBS (1.94 and 1.56 collisions/truck/7 years, respectively) (p=0.04 and p=0.008, respectively). However, for drowsy driving-related collisions, the collision rate did not significantly differ between trucks with and without AEBS. The damage amount in neither type of collision (drowsy vs. non-drowsy) significantly differed between trucks with and without AEBS. CONCLUSIONS: Regarding the collision rate of large trucks, AEBS was effective in non-drowsy driving-related collisions, but not in collisions involving drowsy driving. The damage amount was not mitigated for trucks with and without AEBS regardless of the collision type. The limited effect of AEBS for damage-mitigation suggests the need for combined use with other safety-support systems that intervene in driving operations.

Serial Mediation Analysis of Psychological Inflexibility and Daytime Insomnia Rumination in the Relationship Between Dysfunctional Beliefs About Sleep and Insomnia in College Students.

Emerging research suggests that psychological inflexibility may be a factor contributing to the development and maintenance of insomnia. However, less is known about the potential cognitive pathways that may explain this relationship. In this study, we investigated the serial mediating effects of psychological inflexibility and daytime insomnia-related rumination on the association between dysfunctional beliefs and attitudes about sleep (DBAS) and insomnia symptoms. The sample included 490 college students who underwent assessments at two time points over a 1-month period. The results of our mediational tests yielded significant indirect effects, supporting the prediction that psychological inflexibility and daytime insomnia rumination serially mediate the relationship between DBAS and insomnia. The study provides insights into potential mechanisms for insomnia, emphasizing the role of psychological inflexibility in perpetuating maladaptive cognitive processes associated with insomnia. Future researchers should explore other maladaptive responses to insomnia-related concerns and distress, such as worry and safety behaviors, and replicate findings in clinically elevated insomnia samples.

Successful Second Awake Craniotomy Reoperation With Dexmedetomidine After an Initial Abandonment Case Due to Restlessness.

Awake craniotomy (AC) is sometimes aborted due to poor arousal and restlessness. Dexmedetomidine (DEX), an α2-adrenoreceptor agonist, has sedative, analgesic, and anesthetic-sparing effects, with a low risk of respiratory depression, making it effective for intraoperative pain and agitation during the awake phase. We report a case in which AC was successfully performed in combination with low-dose continuous administration of DEX during reoperation in a patient who experienced poor arousal and restlessness during their first surgery, leading to the abandonment of AC. The patient is a 48-year-old male who is scheduled for AC reoperation. Two years ago, the first AC was scheduled and performed under anesthesia with propofol and remifentanil. However, AC was abandoned due to poor intraoperative arousal and restlessness. At reoperation, general anesthesia was induced with propofol and continuous administration of remifentanil (0.1 µg/kg/min); following anesthesia induction (continuous infusion of propofol, remifentanil, and a bolus infusion of fentanyl), DEX was also administered (0.2 µg/kg/hour). We performed a scalp nerve block. Before the awake phase, the propofol dose was decreased as was DEX to 0.1 µg/kg/hour, and propofol and remifentanil were discontinued. The patient gradually awoke without any agitation and restlessness 24 min after stopping propofol and remifentanil and could perform language tasks without any complications. In this case, AC was successfully performed in combination with continuous low-dose administration of DEX at the time of reoperation in a patient who experienced poor arousal and restlessness during their first operation and had to discontinue AC.

Intraoperative microelectrode recording during asleep deep brain stimulation of subthalamic nucleus for Parkinson Disease. A case series with systematic review of the literature.

The use of microelectrode recording (MER) during deep brain stimulation (DBS) for Parkinson Disease is controversial. Furthermore, in asleep DBS anesthesia can impair the ability to record single-cell electric activity.The purpose of this study was to describe our surgical and anesthesiologic protocol for MER assessment during asleep subthalamic nucleus (STN) DBS and to put our findings in the context of a systematic review of the literature. Sixty-three STN electrodes were implanted in 32 patients under general anesthesia. A frameless technique using O-Arm scanning was adopted in all cases. Total intravenous anesthesia, monitored with bispectral index, was administered using a target controlled infusion of both propofol and remifentanil. A systematic review of the literature with metanalysis on MER in asleep vs awake STN DBS for Parkinson Disease was performed. In our series, MER could be reliably recorded in all cases, impacting profoundly on electrode positioning: the final position was located within 2 mm from the planned target only in 42.9% cases. Depth modification > 2 mm was necessary in 21 cases (33.3%), while in 15 cases (23.8%) a different track was used. At 1-year follow-up we observed a significant reduction in LEDD, UPDRS Part III score off-medications, and UPDRS Part III score on medications, as compared to baseline. The systematic review of the literature yielded 23 papers; adding the cases here reported, overall 1258 asleep DBS cases using MER are described. This technique was safe and effective: metanalysis showed similar, if not better, outcome of asleep vs awake patients operated using MER. MER are a useful and reliable tool during asleep STN DBS, leading to a fine tuning of electrode position in the majority of cases. Collaboration between neurosurgeon, neurophysiologist and neuroanesthesiologist is crucial, since slight modifications of sedation level can impact profoundly on MER reliability.

Mapping of Capsular Side Effects by using Intraoperative Motor-Evoked Potentials during Asleep Deep Brain Stimulation Surgery of the Subthalamic Nucleus for Parkinson's Disease.

INTRODUCTION: The aim of this study was to present a novel technique for subthalamic nucleus (STN) deep brain stimulation (DBS) implantation under general anesthesia by using intraoperative motor-evoked potentials (MEPs) through direct lead stimulation and determining their correlation to the thresholds of postoperative stimulation-induced side effects. METHODS: This study included 22 consecutive patients with advanced Parkinson's disease who underwent surgery in our institution between January 2021 and September 2023. All patients underwent bilateral implantation in the STN (44 leads) under general anesthesia without microelectrode recordings (MERs) by using MEPs with electrostimulation directly through the DBS lead. No cortical stimulation was performed during this process. Intraoperative fluoroscopic guidance and immediate postoperative computed tomography were used to verify the electrode's position. The lowest MEP thresholds were recorded and were correlated to the postoperative stimulation-induced side-effect threshold. The predictive values of the MEPs were analyzed. Five DBS leads were repositioned intraoperatively due to the MEP results. RESULTS: A moderately strong positive correlation was found between the MEP threshold and the capsular side-effect threshold (RS = 0.425, 95% CI, 0.17-0.67, p = 0.004). The highest sensitivity and specificity for predicting a side-effect threshold of 5 mA were found to be at 2.4 mA MEP threshold (sensitivity 97%, specificity 87.5%, positive predictive value 97%, and negative predictive value 87.5%). We also found high sensitivity and specificity (100%) at 1.15 mA MEP threshold and 3 mA side-effect threshold. Out of the total 44 leads, 5 (11.3%) leads were repositioned intraoperatively due to MEP thresholds lower than 1 mA (4 leads) or higher than 5 mA (1 lead). The mean accuracy on postoperative CT was 1.05 mm, and there were no postoperative side-effects under 2.8 mA. CONCLUSION: Intraoperative MEPs with electrostimulation directly through the contacts of the DBS lead correlate with the stimulation-induced capsular side effects. The lead reposition based on intraoperative MEP may enlarge the therapeutic window of DBS stimulation.

Pilot Trial on Awake Surgery for Low-Grade Arteriovenous Malformations in Speech Area and Systematic Review of the Literature.

OBJECTIVE: One of the pressing constraints in the treatment of arteriovenous malformations (AVM) is the potential development of new neurologic deficits, mainly when the AVM is in an eloquent area. The risk of ischemia when an en passage arterial supply is present is not negligible. In this regard, awake surgery holds promise in increasing the safety of low-grade AVM resection. METHODS: We conducted a pilot trial on 3 patients with low-grade AVMs affecting speech areas to evaluate the safety of awake craniotomy using Conscious Sedation. Each feeder was temporarily clipped before the section. Also, we performed a systematic review to analyze the existing data about the impact of awake surgery in eloquent AVM resection. RESULTS: None of the 3 patients presented with neurologic deficits after the procedure. Awake craniotomy was useful in 1 case, as it allowed the detection of speech arrest during the temporal clipping of 1 of the feeders. This vessel was identified as an en passage vessel, closer to the nidus. The second attempt revealed the feeder of the AVM, which was sectioned. Systematic review yielded 7 studies meeting our inclusion criteria. Twenty-six of 33 patients included in these studies presented with AVM affecting speech area. Only 2 studies included the motor evoked potentials. Six studies used direct cortical and subcortical stimulation. In all studies the asleep-awake-asleep technique was used. CONCLUSIONS: Awake craniotomies are safe procedures and may be helpful in avoiding ischemic complications in low-grade AVMs, either affecting eloquent areas and/or when en passage feeders are present.

Clinical evaluation of a stereotactic system for single-stage deep brain stimulation surgery under general anesthesia: technical note.

OBJECTIVE: Conventional frame-based stereotactic systems have circumferential base frames, often necessitating deep brain stimulation (DBS) surgery in two stages: intracranial electrode insertion followed by surgical re-preparation and pulse generator implantation. Some patients do not tolerate awake surgery, underscoring the need for a safe alternative for asleep DBS surgery. A frame-based stereotactic system with a skull-mounted "key" in lieu of a circumferential base frame received US FDA clearance. The authors describe the system's application for single-stage, asleep DBS surgery in 8 patients at their institution and review its workflow and technical considerations. METHODS: Eight patients underwent DBS lead insertion and IPG implantation in a single surgical preparation under general anesthesia using the system. Postoperative CT imaging confirmed lead placement. RESULTS: Eight patients underwent implantation of 15 total leads targeting the ventral intermediate nucleus (4 patients), globus pallidus internus (GPi; 3 patients), and subthalamic nucleus (STN; 1 patient). Intraoperative microelectrode recording was conducted for GPi and STN targets. Postoperative CT imaging revealed a mean ± SD radial error of 1.24 ± 0.45 mm (n = 15 leads), without surgical complications. CONCLUSIONS: The stereotactic system facilitated safe and effective asleep, single-stage DBS surgery, maintaining traditional lead accuracy standards.

Embracing sleep-onset complexity.

Sleep is crucial for many vital functions and has been extensively studied. By contrast, the sleep-onset period (SOP), often portrayed as a mere prelude to sleep, has been largely overlooked and remains poorly characterized. Recent findings, however, have reignited interest in this transitional period and have shed light on its neural mechanisms, cognitive dynamics, and clinical implications. This review synthesizes the existing knowledge about the SOP in humans. We first examine the current definition of the SOP and its limits, and consider the dynamic and complex electrophysiological changes that accompany the descent to sleep. We then describe the interplay between internal and external processing during the wake-to-sleep transition. Finally, we discuss the putative cognitive benefits of the SOP and identify novel directions to better diagnose sleep-onset disorders.

Is This a Deceased Loved One That I See Before Me or Am I Only Dreaming?

This article makes a case for examining dying person's visions during wakefulness and their dreams during sleep as separate and unique phenomena. The reason being that the mode of experience, for example, being visited by a deceased loved one while awake and conscious vs having a deceased loved one appear in a dream while asleep, may have a different impact on the dying person. A better understanding of the content and impact of waking visions and sleeping dreams, respectively, may be beneficial to both dying persons and their families.

[MINICHAL and items predictors of worst quality of life in men with arterial hypertension]. / MINICHAL e items predictores de peor calidad de vida en el varón con hipertension arterial.

OBJECTIVE: Systemic arterial hypertension is the most important modificable risk factor for morbidity and mortality and a Public Health problem. The objective was to estímate ítems of worse quality of life (Qol) in both domains of the MINICHAL questionarie and the associated variables. METHODS: An observational study of prevalence in men was carried out. Sociodemographic, comorbidity, clinical, examination, control and serum parameters variables were collected. The following questionnaires were applied: MINICHAL, International Physical Activity Questionnaire, International Score of Prostatic Symptomatology and International Index of Erectile Function. Apart from the usual descriptive ones, a bivariate and a multivariate logistic regression were performed, determining Odds Ratio values with a 95% confidence interval. RESULTS: 262 hypertensive patients were analyzed, of which 42% reported worse quality of life in the mental state dimensión compared to 47.3% in the somatic manifestacions dimensión. The multivariate logistic regression analysis showed as outstanding predictor variables: Metabolic Syndrome in the chest pain item without making any effort; the presence of filling symptoms in the item urinate more often; pathological cardiopulmonary auscultation in the item numbness or tingling in some part of the body; the presence of erectile dysfunction in the item difficulty falling asleep. CONCLUSIONS: All the items of the MINICHAL questionnaire that assess the Somatic Manifestations dimension have a very negative impact on the quality of life of patients, and only the difficulty falling asleep item in the Mental State dimension.

OBJECTIVE: La hipertensión arterial es el factor de riesgo modificable más importante para la morbimortalidad y un problema de Salud Pública. El objetivo de este trabajo fue estimar los ítems predictores de peor calidad de vida (CV) en ambos dominios del cuestionario MINICHAL y las variables asociadas. METHODS: Se realizó un estudio observacional de prevalencia en varones. Se recogieron variables sociodemográficas, de comorbilidad, clínicas, de exploración, de control y parámetros séricos. Se aplicaron los cuestionarios MINICHAL, Cuestionario Internacional de Actividad Física, Puntuación Internacional de Sintomatología Prostática e Índice Internacional de Función Eréctil. Aparte de los descriptivos habituales, se realizó una regresión logística bivariada y otra multivariada, determinando valores de Odds Ratio con intervalo de confianza al 95%. RESULTS: Se analizaron 262 hipertensos, de los cuales el 42% refirió peor calidad de vida en la dimensión estado mental frente al 47,3% en la dimensión manifestaciones somáticas. El análisis de regresión logística multivariada mostró como variables predictoras destacadas: el Síndrome metabólico en el ítem dolor en el pecho sin hacer ningún esfuerzo; la presencia de síntomas de llenado en el ítem orinar más a menudo; la auscultación cardiopulmonar patológica en el ítem entumecimiento u hormigueo en alguna parte del cuerpo; la presencia de disfunción eréctil en el ítem dificultad para conciliar el sueño. CONCLUSIONS: Todos los ítems del cuestionario MINICHAL que valoran la dimensión Manifestaciones somáticas provocan un impacto muy negativo en la calidad de vida de los pacientes, y solo el ítem dificultad para conciliar el sueño en la dimensión Estado mental.

Clinical trial design for assessing hypertension medications: are critical circadian chronopharmacological principles being taking into account?

INTRODUCTION: Clinical hypertension trials typically rely on homeostatic principles, including single time-of-day office blood pressure (BP) measurements (OBPM), rather than circadian chronopharmacological principles, including ambulatory monitoring (ABPM) done around-the-clock to derive the asleep systolic BP (SBP) mean and sleep-time relative SBP decline - jointly the strongest prognosticators of cardiovascular disease (CVD) risk and true definition of hypertension - to qualify participants and assess outcomes. AREAS COVERED: Eight chronopharmacological elements are indispensable for design and conduct of hypertension medication trials, mainly those on ingestion-time differences in effects, and also a means of rating quality of investigations. Accordingly, we highlight the findings and shortcomings of: (i) 155 such ingestion-time trials, 83.9% finding at-bedtime/evening treatment more beneficial than conventional upon-awakening/morning treatment; (ii) HOPE and ONTARGET CVD outcomes investigations assessing in the former add-on ramipril at-bedtime and in the latter telmisartan, ramipril, or both in combination in the morning; and (iii) pragmatic TIME CVD outcomes trial. EXPERT OPINION: Failure to incorporate chronopharmacological principals - including ABPM to derive asleep SBP and SBP dipping to qualify subjects as hypertensive and assess CVD risk - results in deficient study design, dubious findings, and unnecessary medical controversy at the expense of advances in patient care.

The association between serum total folic acid concentration and severe difficulty falling asleep in US adults: NHANES 2005-2008.

Objective: The present study aimed to explore the correlation of serum total folic acid concentration with severe difficulty falling asleep among US adults. Methods: Cross-sectional data were collected from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2006 and 2007 to 2008 cycles. Participants were divided into the severe difficulty falling asleep (SDFA) group and the control group according to the monthly frequency of having difficulty falling asleep. Serum total folic acid was taken as independent and dependent variables, respectively. The correlation of serum total folic acid concentration with severe difficulty falling asleep was examined using multivariable logistic regression models, where the adjusted odds ratio (OR) and 95% confidential intervals (CIs) were calculated. Results: Overall, 8,926 individuals from the NHANES 2005 to 2006 and 2007 to 2008 waves were included in the analysis, of whom 683 participants had severe difficulty falling asleep. Higher serum total folic acid concentration (ng/ml) was associated with lower odds of severe difficulty falling asleep after adjusting for potentially confounding factors (OR = 0.98; 95% CI: 0.97-1.00), while participants at the highest quartile had the least odds of severe difficulty falling asleep (OR = 0.55; 95% CI: 0.40-0.74). The subgroup analysis based on gender, smoking history, and diabetes showed that this negative correlation was more significant in males, smokers, and nondiabetic population after adjusting for confounding factors. Conclusion: High levels of serum folic acid were significantly related to less odds of severe difficulty in falling asleep among US adults, suggesting that folic acid supplementation may be beneficial to the prevention and even treatment of severe difficulty falling asleep.

Truck collisions attributed to falling asleep at the wheel in two commercial drivers prescribed oral appliance therapy for obstructive sleep apnea.

Falling asleep at the wheel is attributed to sleepiness, and obstructive sleep apnea is a significant cause of sleepiness that increases the risk of motor vehicle collisions due to falling asleep at the wheel. Although continuous positive airway pressure therapy for obstructive sleep apnea reduces the risk of motor vehicle collisions, similar evidence for alternatives such as oral appliance therapy is lacking. We discuss two truck collisions attributed to microsleep confirmed with dashcam video footage of commercial drivers with obstructive sleep apnea. Our results highlight the current situation where there is insufficient evidence for the prevention and reduction of the risk of motor vehicle collisions by oral appliance therapy, objective adherence monitoring of oral appliance therapy, and effectiveness confirmation tests. Therefore, it is suggested that for commercial truck drivers who require a high level of driving safety, careful selection for oral appliance therapy, systematic follow-up, and monitoring of the driver and truck status with dashcam video footage are crucial. CITATION: Kumagai H, Tsuda H, Kawaguchi K, et al. Truck collisions attributed to falling asleep at the wheel in two commercial drivers prescribed oral appliance therapy for obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):2117-2122.

Malnutrition, Depression, Poor Sleep Quality, and Difficulty Falling Asleep at Night Are Associated with a Higher Risk of Cognitive Frailty in Older Adults during the COVID-19 Restrictions.

The COVID-19 restrictions, such as social isolation and disruption of daily routines, can have detrimental effects, including increased stress, anxiety, sleep disturbance, and physical and cognitive decline among older adults. This study aimed to examine the association between nutritional status, depression, sleep quality, falling asleep at night, and cognitive frailty (CF) among older Thai adults during the COVID-19 pandemic. This cross-sectional study included 408 older adults with an average age of 70.54 (5.49) years. CF was determined using Fried's frailty phenotype and the Montreal Cognitive Assessment Basic. The Mini Nutritional Assessment-Short Form, Pittsburgh Sleep Quality Index, and geriatric depression assessment were used for assessment. Multiple logistic regression analysis demonstrated that participants who were malnourished (OR 3.786; 95%CI 1.719-8.335), depressed (OR 5.003; 95%CI 2.399-10.434), had poor sleep quality (OR 1.613; 95%CI 1.041-2.500), and engaged in difficulty falling asleep (OR 1.809; 95%CI 1.022-3.203) had a higher risk of CF compared to those who did not exhibit these factors. Therefore, malnutrition, depression, poor sleep quality, and difficulty falling asleep were identified as risk factors for CF among older adults in Thailand linked to the impact of the COVID-19 pandemic. It is crucial to develop interventions to prevent CF resulting from the mentioned variables.

How I do it - asleep DBS placement for Parkinson's disease.

BACKGROUND: Traditionally, functional neurosurgery relied in stereotactic atlases and intraoperative micro-registration in awake patients for electrode placement in Parkinson's disease. Cumulative experience on target description, refinement of MRI, and advances in intraoperative imaging has enabled accurate preoperative planning and its implementation with the patient under general anaesthesia. METHODS: Stepwise description, emphasising preoperative planning, and intraoperative imaging verification, for transition to asleep-DBS surgery. CONCLUSION: Direct targeting relies on MRI anatomic landmarks and accounts for interpersonal variability. Indeed, the asleep procedure precludes patient distress. A particular complication to avoid is pneumocephalus; it can lead to brain-shift and potential deviation of electrode trajectory.

The efficacy and safety of asleep and awake subthalamic deep brain stimulation for Parkinson's disease patients: A 1-year follow-up.

Introduction: Traditional DBS is usually conducted under local anesthesia (LA) which is intolerable to some patients, DBS under general anesthesia (GA) was opted to extended surgical indication. This study aimed to compare the efficacy and safety of bilateral subthalamic deep brain stimulation (STN-DBS) for Parkinson's disease (PD) under asleep and awake anesthesia state in 1-year postoperative follow-up. Methods: Twenty-one PD patients were assigned to asleep group and 25 patients to awake group. Patients received bilateral STN-DBS under different anesthesia state. The PD participants were interviewed and assessed preoperatively and at 1-year postoperative follow-up. Results: At 1-year follow-up, compared surgical coordinate in two groups, the left-side Y of asleep group showed more posterior than awake group (Y was-2.39 ± 0.23 in asleep group, -1.46 ± 0.22 in awake group, p = 0.007). Compared with preoperative OFF MED state, MDS-UPDRS III scores in OFF MED/OFF STIM state remained unchanged, while in OFF MED/ON STIM state were significantly improved in awake and asleep groups, yet without significant difference. Compared with preoperative ON MED state, MDS-UPDRS III scores in ON MED/OFF STIM, and ON MED/ON STIM state remained unchanged in both groups. In non-motor outcomes, PSQI, HAMD, and HAMA score significantly improved in asleep group compared to awake group at 1-year follow-up (PSQI, HAMD, and HAMA score in 1-year follow-up were 9.81 ± 4.43; 10.00 ± 5.80; 5.71 ± 4.75 in awake group, 6.64 ± 4.14; 5.32 ± 3.78; 3.76 ± 3.87 in asleep group, p = 0.009; 0.008; 0.015, respectively), while there was no significant difference in PDQ-39, NMSS, ESS, PDSS score, and cognitive function. Anesthesia methods was significantly associated with improvement of HAMA and HAMD score (p = 0.029; 0.002, respectively). No difference in LEDD, stimulation parameters and adverse events was observed between two groups. Discussion: Asleep STN-DBS may be considered a good alternative method for PD patients. It is largely consistent with awake STN-DBS in motor symptoms and safety. Yet, it showed higher improvement in terms of mood and sleep compared to awake group at 1-year follow-up.

Comparison of dexmedetomidine and propofol for sedation in awake craniotomy: A meta-analysis.

BACKGROUND: Awake craniotomy (AC) is the preferred option for the resection of tumors adjacent to eloquent cortical areas and in cases of intractable epilepsy. It is mostly used to maintain the integrity of the brain during intracranial neurosurgical procedures. Awake craniotomy requires the use of ideal anesthetics, hypnotics, and analgesics to balance sedation, prompt the reversal of sedation, and prevent respiratory depression while maintaining communication between patient and medical team. Although a wide variety of anesthetics and hypnotics have been used for awake craniotomy over the past several decades, the optimal drug for the procedure has yet to be determined. The purpose of this meta-analysis was to compare dexmedetomidine and propofol in terms of intraoperative adverse events (i.e., hypertension, hypotension, nausea, vomiting, respiratory depression), patient and surgeon satisfaction, and procedure duration. METHODS: We searched PubMed, Google Scholar, and the Cochrane Library for relevant articles published between the inception of these databases and April of 2022. The systematic search yielded 781 articles. After screening, we excluded 778 articles. The remaining three articles reporting 138 patients were selected for meta-analysis. RESULTS: This meta-analysis showed no statistically significant difference between propofol and dexmedetomidine related to intraoperative adverse events, patient satisfaction, or procedure duration. The only statistically significant result was surgeon satisfaction, which appeared to be higher in the dexmedetomidine group. CONCLUSIONS: Further high-quality randomized and controlled trials are needed to find a preferred agent for intraoperative sedation in awake craniotomy.

Association of clinical outcomes and connectivity in awake versus asleep deep brain stimulation for Parkinson disease.

OBJECTIVE: Deep brain stimulation (DBS) for Parkinson disease (PD) is traditionally performed with awake intraoperative testing and/or microelectrode recording. Recently, however, the procedure has been increasingly performed under general anesthesia with image-based verification. The authors sought to compare structural and functional networks engaged by awake and asleep PD-DBS of the subthalamic nucleus (STN) and correlate them with clinical outcomes. METHODS: Levodopa equivalent daily dose (LEDD), pre- and postoperative motor scores on the Movement Disorders Society-Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS III), and total electrical energy delivered (TEED) at 6 months were retroactively assessed in patients with PD who received implants of bilateral DBS leads. In subset analysis, implanted electrodes were reconstructed using the Lead-DBS toolbox. Volumes of tissue activated (VTAs) were used as seed points in group volumetric and connectivity analysis. RESULTS: The clinical courses of 122 patients (52 asleep, 70 awake) were reviewed. Operating room and procedure times were significantly shorter in asleep cases. LEDD reduction, MDS-UPDRS III score improvement, and TEED at the 6-month follow-up did not differ between groups. In subset analysis (n = 40), proximity of active contact, VTA overlap, and desired network fiber counts with motor STN correlated with lower DBS energy requirement and improved motor scores. Discriminative structural fiber tracts involving supplementary motor area, thalamus, and brainstem were associated with optimal clinical improvement. Areas of highest structural and functional connectivity with VTAs did not significantly differ between the two groups. CONCLUSIONS: Compared to awake STN DBS, asleep procedures can achieve similarly optimal targeting-based on clinical outcomes, electrode placement, and connectivity estimates-in more efficient procedures and shorter operating room times.

Identifying the therapeutic zone in globus pallidus deep brain stimulation for Parkinson's disease.

OBJECTIVE: The globus pallidus internus (GPI) has been demonstrated to be an effective surgical target for deep brain stimulation (DBS) treatment in patients with medication-refractory Parkinson's disease (PD). The ability of neurosurgeons to define the area of greatest therapeutic benefit within the globus pallidus (GP) may improve clinical outcomes in these patients. The objective of this study was to determine the best DBS therapeutic implantation site within the GP for effective treatment in PD patients. METHODS: The authors performed a retrospective review of 56 patients who underwent bilateral GP DBS implantation at their institution during the period from January 2015 to January 2020. Each implanted contact was anatomically localized. Patients were followed for stimulation programming for at least 6 months. The authors reviewed preoperative and 6-month postsurgery clinical outcomes based on data from the Unified Parkinson's Disease Rating Scale Part III (UPDRS III), dyskinesia scores, and levodopa equivalent daily dose (LEDD). RESULTS: Of the 112 leads implanted, the therapeutic cathode was most frequently located in the lamina between the GPI external segment (GPIe) and the GP externus (GPE) (n = 40). Other common locations included the GPE (n = 24), the GPIe (n = 15), and the lamina between the GPI internal segment (GPIi) and the GPIe (n = 14). In the majority of patients (73%) a monopolar programming configuration was used. At 6 months postsurgery, UPDRS III off medications (OFF) and on stimulation (ON) scores significantly improved (z = -4.02, p < 0.001), as did postsurgery dyskinesia ON scores (z = -4.08, p < 0.001) and postsurgery LEDD (z = -4.7, p < 0.001). CONCLUSIONS: Though the ventral GP (pallidotomy target) has been a commonly used target for GP DBS, a more dorsolateral target may be more effective for neuromodulation strategies. The assessment of therapeutic contact locations performed in this study showed that the lamina between GPI and GPE used in most patients is the optimal central stimulation target. This information should improve preoperative GP targeting.