Introduction
Deep Brain Stimulation (DBS) for the therapeutic management of Parkinson’s disease (PD) and other movement disorders is a widely practiced and accepted treatment option,1 with an estimated 12 000 DBS procedures performed each year worldwide.2 In PD, DBS has been shown to improve motor control, activities of daily living, sleep, urinary dysfunction, quality of life and longevity, as well as reduce levodopa-induced motor and non-motor complications.3 4 It is at least as effective as infusional therapies5 in patients experiencing motor fluctuations and dyskinesia, and the only effective treatment option in patients with L-dopa refractory tremor or intolerance to dopaminergic therapies.
Despite 30 years of clinical experience and widespread availability in developed countries, uptake remains relatively modest, with only an estimated 10–15%6 7 of eligible patients electing to pursue the therapy. Therapeutic reluctance has been shown to relate to both referrer and patient factors, noting that some patients report having to ‘convince’ or ‘demand’ their physician refer them for surgical consideration.8 Referral reluctance is proposed to relate to an overestimation of adverse events experienced post DBS surgery,7 as well as a limited understanding of DBS indications in PD.7
Patient hesitancy has been shown to relate to uncertainty regarding the benefits, concerns about the implantation procedure itself and the possibility of adverse events.9 Procedural concerns include the potential economic burden6 10 11 and fear of being awake during the surgery.6 Prospective patients worry about medium and long-term alterations in mood and emotional well-being,6 10 and the possibility of surgical complications.6 11
Studies indicate that fear of surgical complications is a significant contributor to patient hesitancy, with one cohort reporting 46.3% of patients held fear around the risk of intracranial bleeding or permanent neurological deficits.7 Patient concern is also reflected by the findings Kim M.R et al, who reported that 74% of patients identified that a fear of adverse events related to surgery or DBS outcomes contributed to their initial reluctance to proceed.11
The reported rates for intracranial haemorrhage (ICH) in DBS for PD are highly variable (ranging from 0.44% to 8%4 12–26 with an average of 2.4% per patient).24 Concerns about ICH weigh heavily in a risk/benefit evaluation of surgery for patients, particularly in those earlier in the course of PD who may be managing, although suboptimally, with their Parkinsonian symptoms.
Together, these physician and patient considerations contribute to a prevailing view, despite strong scientific evidence to the contrary,27 that DBS is a ‘last resort’ therapy. This perspective assumes DBS is not to be considered in the earlier stages of disease process6 8 when the response is, in fact, most durable and there is the most effective delay on disability that progressively impacts relationships, employment and social participation.3
Reducing vascular complications of DBS is critical in improving the acceptance and accessibility of the procedure. Here, we report on the incidence of cerebrovascular complications from a single surgeon/neurologist implanting team in a large consecutive series of 600 bilateral DBS implantations for PD from 2001 to 2023. Operative risk reduction strategies are explored, including those facilitated by advances in imaging quality, image fusion software and electrode implantation technique.