Deep Brain Stimulator Insertion
Patient phenotype
Parkinson's disease (most common), essential tremor, dystonia. 50s-70s. Patients often on dopamine agonists, levodopa, sometimes deprenyl (MAOI) — drug interactions.
Procedure
Stereotactic frame placement (Leksell). MRI/CT for targeting. Two-stage: lead placement (awake) → IPG placement (later, usually GA). Lead placement is the long awake portion.
Anesthetic plan
MAC for lead placement (must be awake for microelectrode recording + symptom check). GA for IPG. Lead phase: light sedation or none, dex preferred (no respiratory depression, allows cooperation, preserves microelectrode recording).
Setup
- ·Standard monitors
- ·1 PIV
- ·A-line if HTN or comorbidities
- ·Dex infusion (0.2-0.7 mcg/kg/h)
- ·Frame on patient — anesthesia must coordinate with neurosurgeon
- ·Neuro-monitoring (microelectrode recording + intraop symptom check)
Biggest concerns by phase
Parkinson's medication management
Levodopa: continue morning of (avoid 'off' state). Dopamine agonists: continue. Deprenyl/selegiline (MAOI-B): hold > 2 wks before to avoid serotonin syndrome with opioids. Carbidopa+levodopa via NG if NPO.
Frame placement — uncomfortable + claustrophobic
Stereotactic frame screwed into skull (local anesthesia). Patient awake throughout. Anxiolysis: small dose dex or midaz (limited — interferes with MER).
Awake lead placement — minimal sedation
Microelectrode recording requires patient awake for testing tremor/rigidity. Dex 0.2-0.4 mcg/kg/h light infusion. NO benzo (suppresses tremor). NO opioid (suppresses tremor + respiratory drive). Reposition only when surgeon allows.
Air embolism — head-up + open dura
Sitting/semi-sitting with skull open = VAE risk. Watch for sudden ETCO₂ drop, hypotension, mill-wheel murmur. Treatment: flood field, jugular compression, head-down, FiO₂ 100%, hemodynamic support.
Intracerebral hemorrhage during lead pass
1-3% incidence. Sudden neuro change, BP spike, seizure. CT in OR or convert to GA + decompression.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
62-yo with advanced PD on levodopa/carbidopa + selegiline, scheduled DBS lead placement. Husband worried about her staying still. Plan?
What an examiner probes for
- ▹Hold MAOI (selegiline) 2 wks pre
- ▹Continue levodopa morning of
- ▹Dex-only sedation, no benzo or opioid
- ▹Frame management + anxiety
- ▹VAE + ICH preparedness
Sources
- Cottrell Neuroanesthesia 6e
- Anesthesiology DBS Review (Venkatraghavan)
Anatomy reference
Sourced reference images. 4 matches for "brain cortex thalamus".
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