Objective: Deep brain stimulation (DBS) has traditionally been performed “awake” under local anesthesia using intra-operative test stimulation to confirm lead placement. Several recent studies have demonstrated similar outcomes between asleep and awake DBS procedures.^1-5 Our study compared safety and clinical outcomes of asleep (ASP) versus awake (AWK) DBS from a real-world global population.

Background: Advances in neuroimaging have led to image-guided ASP DBS procedure, without use of test stimulation, primarily in consideration of patient comfort. Recent literature suggests the orientation of the patient’s head during DBS surgery may affect the accuracy of electrode placement due to brain shift related to the position of the brain relative to the skull.⁶ Since patients undergoing ASP DBS depend on anatomically stable targeting based on pre-operative imaging, a flat head position during surgery similar to that captured in imaging may be less prone to subtle brain shift which may occur during AWK procedures.

Method: The Product Surveillance Registry (PSR) is a prospective, multi-center global registry for DBS. This analysis represents data from 197 therapy-naïve PD and 126 ET patients at 26 centers from April 2016-April 2019, for which type of anesthesia was determined by treating clinicians. Assessments were recorded at baseline and within the first year of follow-up. Clinical outcome was assessed using EQ-5D summary index scores.
Statistical tests of within- and between-group changes in the EQ-5D were conducted using Wilcoxon rank tests. Fisher’s Exact tests compared complication rates.

Results: Within PD patients, ASP group was slightly younger than the AWK group at enrollment (60±10 vs 63±10 years, p=0.028). Average years from disease onset was 9±4 (p=0.89) in both groups. For ET patients, no significant difference in age distribution (68±12 in ASP and 63±14 years in AWK, p=0.20).
EQ-5D index scores significantly improved for both the ASP and AWK groups within PD patients, but improvement was not significantly different between groups (p=0.59).  The occurrence of serious adverse events was similar between groups at follow-up (8.4% for ASP and 8.8% for AWK PD patients).

Conclusion: Published literature has shown that the accuracy and clinical outcomes of ASP DBS are similar to AWK DBS. The PSR data from real-world PD and ET patients support the conclusion that no significant advantages were found by type of DBS procedure.

References: 1. Brodsky MAA, S.; Murchison, C.; Seier, M.; Wilhelm, J.; Vederman, A.; Burchiel, K. J. Clinical outcomes of asleep vs awake deep brain stimulation for Parkinson disease. Neurology 2017;89:1944-50. 2. Chen T, Mirzadeh Z, Chapple KM, et al. Clinical outcomes following awake and asleep deep brain stimulation for Parkinson’s disease. J Neurosurg 2018:1-12. 3. Chen TM, Z.; Chapple, K.; Lambert, M.; Shill, H.; Moguel-Cobos, G.; Dhall, R.; Troster, A.; Ponce, F. A. . Clinical outcomes following awake and asleep deep brain stimulation for Parkinson’s disease. Clinical neurosurgery 2017;64:259. 4. Ho AL, Ali R, Connolly ID, et al. Awake versus asleep deep brain stimulation for Parkinson’s disease: a critical comparison and meta-analysis. J Neurol Neurosurg Psychiatry 2017. 5. Wang J, Ponce FA, Tao J, Yu HM, Liu JY, Wang YJ, Luan GM, Ou SW. Comparison of Awake and Asleep Deep Brain Stimulation for Parkinson’s Disease: A Detailed Analysis Through Literature Review. Neuromodulation 2019 Dec 12. doi: 10.1111/ner.13061. [Epub ahead of print]. 6. Mirzadeh Z, Chen T, Chapple KM et al. Procedural variables influencing stereotactic accuracy and efficiency in deep brain stimulation surgery. Oper Neurosurg (Hagerstown) 2018;17:70–78.

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