Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment.

BACKGROUND: In the aging society, many patients with movement disorders, pain syndromes, or psychiatric disorders who are candidates for deep brain stimulation (DBS) surgery suffer also from cardiovascular co-morbidities that require chronic antiplatelet or anticoagulation treatment. Because of a presumed increased risk of intracranial hemorrhage during or after surgery and limited knowledge about perioperative management, chronic antiplatelet or anticoagulation treatment often has been considered a relative contraindication for DBS. Here, we evaluate whether or not there is an increased risk for intracranial hemorrhage or thromboembolic complications in patients on chronic treatment (paused for surgery or bridged with subcutaneous heparin) as compared to those without. METHODS: Out of a series of 465 patients undergoing functional stereotactic neurosurgery, 34 patients were identified who were on chronic treatment before and after receiving DBS. In patients with antiplatelet treatment, medication was stopped in the perioperative period. In patients with vitamin K antagonists or novel oral anticoagulants (NOACs), heparin was used for bridging. All patients had postoperative stereotactic CT scans, and were followed up for 1 year after surgery. RESULTS: In patients on chronic antiplatelet or anticoagulation treatment, intracranial hemorrhage occurred in 2/34 (5.9%) DBS surgeries, whereas the rate of intracranial hemorrhage was 15/431 (3.5%) in those without, which was statistically not significant. Implantable pulse generator pocket hematomas were seen in 2/34 (5.9%) surgeries in patients on chronic treatment and in 4/426 (0.9%) without. There were only 2 instances of thromboembolic complications which both occurred in patients without chronic treatment. There were no hemorrhagic complications during follow-up for 1 year. CONCLUSIONS: DBS surgery in patients on chronic antiplatelet or anticoagulation treatment is feasible. Also, there was no increased risk of hemorrhage in the first year of follow-up after DBS surgery. Appropriate patient selection and standardized perioperative management are necessary to reduce the risk of intracranial hemorrhage and thromboembolic complications.

Microvascular decompression: is routine postoperative CT imaging necessary?

BACKGROUND: Postoperative head CT imaging is routinely performed for detection of postoperative complications following intracranial procedures. However, it remains unclear whether with regard to radiation exposure, costs, and possibly lack of consequences this practice is truly justified in various operative procedures. The objective of this study was to analyze whether routine postoperative CT imaging after microvascular decompression (MVD) is necessary or whether it may be abandoned. METHODS: A series of 202 MVD surgeries for trigeminal neuralgia (179), hemifacial spasm (17), vagoglossopharyngeal neuralgia (2), paroxysmal vertigo (2), and pulsatile tinnitus (2) operated by the senior surgeon (JKK) and who had postoperative routine CT imaging was analyzed. RESULTS: Routine postoperative CT imaging detected small circumscribed postoperative hemorrhage in 9/202 (4.4%) instances. Hemorrhage was localized at the site of the Teflon felt (1/9), the cerebellum (4/9), in the frontal subdural space (3/9), and in the frontal subarachnoid space (1/9). In two patients, asymptomatic hemorrhage was accompanied by mild cerebellar edema (1%), and another patient had mild transient hydrocephalus (0.5%). Furthermore, there were small accumulations of intracranial air in 86/202 instances. No other complications such as infarction or skull fracture secondary to fixation with the Mayfield clamp were detected. MVD had been performed for trigeminal neuralgia in 6/9 patients, for hemifacial spasm in 2/9, and in one patient with both. No patient underwent a second surgery. Hemorrhage was symptomatic at the time of imaging in only one instance who had mild postoperative gait ataxia. Two patients with hemorrhage developed delayed facial palsy most likely unrelated to hemorrhage which remitted with corticosteroid treatment. At 3-month follow-up and at long-term follow-up, they had no neurological deficits. CONCLUSION: Routine postoperative CT imaging is not necessary after MVD in a standard setting in patients who do not have postoperative neurological deficits.

Are Transventricular Approaches Associated With Increased Hemorrhage? A Comparative Study in a Series of 624 Deep Brain Stimulation Surgeries.

BACKGROUND: Deep brain stimulation (DBS) surgery has advanced tremendously, for both clinical applications and technology. Although DBS surgery is an overall safe procedure, rare side effects, in particular, hemorrhage, may result in devastating consequences. Although there are certain advantages with transventricular trajectories, it has been reasoned that avoidance of such trajectories would likely reduce hemorrhage. OBJECTIVE: To investigate the possible impact of a transventricular trajectory as compared with a transcerebral approach on the occurrence of symptomatic and asymptomatic hemorrhage after DBS electrode placement. METHODS: Retrospective evaluation of 624 DBS surgeries in 582 patients, who underwent DBS surgery for movement disorders, chronic pain, or psychiatric disorders. A stereotactic guiding cannula was routinely used for DBS electrode insertion. All patients had postoperative computed tomography scans within 24 hours after surgery. RESULTS: Transventricular transgression was identified in 404/624 DBS surgeries. The frequency of hemorrhage was slightly higher in transventricular than in transcerebral DBS surgeries (15/404, 3.7% vs 6/220, 2.7%). While 7/15 patients in the transventricular DBS surgery group had a hemorrhage located in the ventricle, 6 had an intracerebral hemorrhage along the electrode trajectory unrelated to transgression of the ventricle and 2 had a subdural hematoma. Among the 7 patients with a hemorrhage located in the ventricle, only one became symptomatic. Overall, a total of 7/404 patients in the transventricular DBS surgery group had a symptomatic hemorrhage, whereas the hemorrhage remained asymptomatic in all 6/220 patients in the transcerebral DBS surgery group. CONCLUSION: Transventricular approaches in DBS surgery can be performed safely, in general, when special precautions such as using a guiding cannula are routinely applied.