Objective: To present a case with a severe life-threatening microlesion effect related with STN DBS rescued with a tractography-guided neuromodulation approach

Background: Microlesion effect have been described as a transient clinical improvement after lead penetration in the target area in patients undergoing deep brain stimulation. Severe persistent dyskinesia after DBS lead placement in the subthalamic nucleus have been rarely described².

Method: We report a case of a 67-year-old woman diagnosed with PD fifteen years before the surgery. The levodopa-equivalent daily dose was 325 mg before surgery and the UPDRS OFF was 23 and ON was 0. She underwent DBS with directional leads in a staged fashion. After the right lead was implanted she was discharged home with no complications. Two days later the patient started with dyskinesias in the left hemibody (USCRS⁸item 16: 6). The first approach was to discontinue the levodopa and prescribe long-acting amantadine with no improvement. Three days later the dyskinesias worsened and the patient had to be admitted to the intensive care unit due to severe dyskinesias, rhabdomyolysis, and metabolic acidosis. We tetrabenazine with improvement of the dyskinesias but worsening of the Parkinsonism.

Results: We performed a tractography analysis to identify the pallidofugal pathways (Fig 1). The most dorsal (fourth) contact and the anteromedial/posterior segments of the third contact had direct access to this pathway. She underwent bilateral internal pulse generator implantation. Immediately after the surgery, we activated the fourth contact and the dyskinesias dramatically improved (USCRS 2). The improvement was optimized by adding the anteromedial and posterior segments of the third contact (settings: 4-3AB-C+, 90 µs, 130Hz) with total suppression of the rest dyskinesias and ~75% reduction of the action dyskinesias. Brief discontinuation of the stimulation resulted in a relapse of severe dyskinesias. Postoperative MRI of the brain did not show evidence of stroke or bleeding in the subthalamic area.

Conclusion: In summary, severe dyskinesias related with microlesion effect could be rescued with pallidofugal stimulation if the most dorsal contacts have access to this antidyskinetic circuit. This strategy may avoid the need to reimplant in the GPi area. Tractography can identify this pathway individually with good anatomical accuracy in a patient-specific manner.

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