Surgical Management of Deep Brain Stimulator Infection without Electrode Removal: Report of Two Cases

Abstract

Objective Stimulation of the subthalamic nucleus by implanted electrodes (deep brain stimulation [DBS]) is performed to suppress symptoms of Parkinson's disease. However, postoperative wound dehiscence and infection can require removal of the implanted electrode leads. This report describes treatment of intractable unilateral wound infection in two patients without removing the DBS device.

Methods First, components of the DBS system were removed except for the electrode lead and thorough debridement of the infected wound was conducted. Second, the edges of the bone defect left by removal of DBS components were smoothed to eliminate dead space. Subsequently, the electrode lead was covered by using a pericranial-frontalis-muscle flap or a bi-pedicled-scalp flap with good blood supply. Closed intrawound continuous negative pressure and irrigation treatment was conducted for 1 week after the surgery, and then the drain was removed.

Results We treated two patients with wound infection after implantation of DBS electrodes. Case 1 developed a cutaneous fistula and Case 2 had wound dehiscence. After treatment by the method described above, complete wound healing was achieved in both patients.

Conclusion DBS is always associated with a risk of infection or exposure of components and treatment can be very difficult. We successfully managed intractable wound infection while leaving the electrode lead in situ, so that it was subsequently possible to continue DBS for Parkinson's disease.

Keywords

deep brain stimulation - electrode lead - infection - intractable wound - cutaneous fistula - intrawound continuous negative pressure and irrigation therapy - reconstruction - pericranial flap - scalp flap

• References

• 1 Benabid AL, Pollak P, Louveau A, Henry S, de Rougemont J. Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease. Appl Neurophysiol 1987; 50 (1-6): 344-346
• 2 Benabid AL, Benazzouz A, Hoffmann D, Limousin P, Krack P, Pollak P. Long-term electrical inhibition of deep brain targets in movement disorders. Mov Disord 1998; 13 (Suppl 3): 119-125
• 3 Chen T, Mirzadeh Z, Lambert M. , et al. Cost of deep brain stimulation infection resulting in explantation. Stereotact Funct Neurosurg 2017; 95 (02) 117-124
• 4 Wetzelaer P, Vlis T, Tonge M. , et al. Management of hardware related infections after DBS surgery: a cost analysis. Turk Neurosurg 2018; 28 (06) 929-933
• 5 Takagi M, Kiyokawa K, Sakamoto A. , et al. Two-stage reconstructive surgery of a patient with head trauma resulting in extensive cranial bone and dura mater loss caused by postoperative infection: usefulness of a pericranial flap for dura mater reconstruction. J Craniofac Surg 2006; 17 (03) 584-590
• 6 Kiyokawa K, Takahashi N, Rikimaru H, Yamauchi T, Inoue Y. New continuous negative-pressure and irrigation treatment for infected wounds and intractable ulcers. Plast Reconstr Surg 2007; 120 (05) 1257-1265
• 7 Oyama M, Rikimaru H, Migita H, Sakata K, Kiyokawa K. The efficacy of continuous negative pressure and irrigation treatment inside the wound by a closed system in reconstruction of all layers of the cranium accompanying infection and cerebrospinal fluid leakage. J Craniofac Surg 2016; 27 (01) e10-e13
• 8 Staudt MD, Pourtaheri N, Lakin GE, Soltanian HT, Miller JP. Surgical management of deep brain stimulator scalp erosion without hardware removal. Stereotact Funct Neurosurg 2017; 95 (06) 385-391
• 9 Horowitz JH, Persing JA, Nichter LS, Morgan RF, Edgerton MT. Galeal-pericranial flaps in head and neck reconstruction. Anatomy and application. Am J Surg 1984; 148 (04) 489-497
• 10 Takumi I, Akimoto M, Hironaka K. , et al. Pedicle galeo-pericranial flap augmentation in salvage frontotemporal cranioplasty: additional ‘neurosurgeon-friendly’ reconstruction technique of aesthetic neurosurgery in superficial temporal artery branch compromised host. Neurol Med Chir (Tokyo) 2018; 58 (08) 350-355
• 11 Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38 (06) 563-576 , discussion 577
• 12 Rikimaru H, Rikimaru-Nishi Y, Yamauchi D, Ino K, Kiyokawa K. New alternative therapeutic strategy for Gustilo type IIIB open fractures, using an intra-wound continuous negative pressure irrigation treatment system. Kurume Med J, In press
• 13 Morinaga K, Rikimaru Y, Kiyokawa K. Treatment of abdominal surgical wound dehiscence with bowel exposure and infection: using intrawound continuous negative pressure, irrigation, and application of artificial dermis. Ann Plast Surg 2019; 82 (02) 213-217