An Electrode-preserved Patient after Bilateral Intracranial Hematoma Induced by Deep Brain Stimulation.

To the Editor: Deep brain stimulation (DBS) is widely used in Parkinson's disease. Here, we report a bilateral hemorrhage case related to subthalamic nucleus (STN)-DBS. In this case, we preserved the electrode, and the curative effect is still satisfied after 2 years.

A 66-year-old female was admitted to Beijing Tiantan Hospital with 10 years Parkinson's disease (Unified Parkinson Disease Rating Scale [UPDRS] part III [motor examination] score 12/41 [on/off medication]). She was also diagnosed as hypertension for 4 years and treated with nifedipine controlled-release tablets (Adalat GITS, Bayer, Germany). The systolic pressure was usually between 130 and 150 mmHg with a large fluctuation nevertheless. The highest systolic pressure was reported reaching 180 mmHg. Bilateral STN-DBS was conducted and one time of microelectrode recording in both sides. The operation was finished successfully. However after 8 h, the patient was found unconscious with unequal pupils and a blunt light reflex. Computed tomography (CT) indicated hematoma in right frontal lobe [Figure 1a]. An emergency operation was performed. The bone flap around the electrode was kept, and the electrode was preserved. Surprisingly, CT showed that new hematoma in left frontal lobe the next day [Figure 1b]. Considering the patient's age and the hemorrhage were not large, we adopted conservative treatment, as a result, the hemorrhage became smaller under dynamic view [Figure 1c]. The patient was discharged 2 weeks later. The stimulator (Activa PC, 37601, Medtronic, USA) was turned on 5 months after the operation. The UPDRS-III score 5/29 (on/off stimulation) demonstrated that the electrode works well after 2 years.

Figure 1

Postoperative computed tomography data indicating the disease evolution in this case. (a) A computed tomography scan 8 h after the first operation; (b) A computed tomography scan 8 h after the second operation; (c) A computed tomography scan 13 day after the second operation.

Because DBS is generally safe, preoperative preparation may not get enough attention. However, some complications are fatal like this case. Bilateral hematoma after DBS is rare to see, and we are regretful for not sending the pathology of the hematoma. According to the previous article, hypertension is the most significant risk factor for intracranial hemorrhage (ICH),[1] but it does not raise enough concern, especially when accompany with other diseases and with large fluctuation.[23] During and after DBS, we should control the blood pressure in a stable state for patients who have large blood pressure variability to decrease the ICH tendency. Some patients in our center are diagnosed as amyloidosis which is related to hematoma after DBS surgery because of the fibroid necrosis and microaneurysms.[4] Susceptibility weighted imaging is effective in detecting hemorrhage in the central nervous system before surgery.[5] If the hematoma appears, we need to protect the bone flap and the electrode during the hematoma clearance operation. The therapeutic effect will be kept if the two sides of the electrode are stable. Once the electrode is pulled out, it is difficult to place again due to the moved structure and the absorption of the hematoma in the chronic stage. In most cases, we remove the electrode as the hematoma may push the electrode and the electrode is negative for the hematoma absorption. However in this case, we kept the electrode and the therapeutic effect is good after 2 years. This indicates that electrode can be preserved even the hematoma emerged after surgery. Furthermore, our experience showed that we should wait a longer time before turning on the stimulator since the electrode needs a longer time to interact with the surrounding tissues.

Financial support and sponsorship

This study was supported by grants from the National Natural Science Foundation of China (No. 81301183), the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding (No. ZYLX201305) and the Scientific Research Common Program of Beijing Municipal Commission of Education (No. KZ201510025029).

Conflicts of interest

There are no conflicts of interest.