Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel.
Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel.
Neurobiol Dis. 2022 Aug;170:105747. doi: 10.1016/j.nbd.2022.105747. Epub 2022 May 10.
Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to optimize brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS borders and subdomains based on electrophysiological properties like firing rates and patterns, intra-operative evaluation of therapeutic window, and improvement of lead placement accuracy. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties and interference with clinical testing, resulting in potential impact on surgical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring.
This open-label study investigates the use of low-dose ketamine for conscious sedation during microelectrode recordings and lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients.
Three anesthetic regimens were retrospectively compared in 38 surgeries (74 MER trajectories, 5962 recording sites) across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA).
All anesthesia regimens achieved satisfactory MER. Detection of STN borders and subdomains by expert electrophysiologist was similar between the groups. Electrophysiological signature of the STN under ketamine was not inferior to either control group. All patients completed stimulation testing.
This study supports a low-dose ketamine anesthesia regimen for DBS which allows microelectrode recordings and stimulation testing that are not inferior to those conducted under awake and propofol-awake regimens and may optimize patient experience. A prospective double-blind study that would also compare patients' satisfaction level and clinical outcome should be performed to confirm these findings.
深部脑刺激（DBS）常用于选择性帕金森病患者，且安全有效。许多中心在局部麻醉下进行 DBS 导联定位，以优化脑微电极记录（MER）和测试刺激相关的治疗效果和副作用。这些措施可以根据放电率和模式等电生理特性，对 DBS 边界和亚区进行生理识别，评估术中治疗窗，并提高导联放置的准确性。然而，由于清醒手术的挑战，一些中心尽管存在放电特性失真和临床测试干扰的风险，仍使用镇静或全身麻醉，从而对手术结果产生潜在影响。因此，需要一种新的麻醉方案，在不影响术中监测的情况下实现镇静。
本开放性研究旨在调查在帕金森病患者的丘脑底核（STN）DBS 中，使用小剂量氯胺酮进行微电极记录和导联定位时的清醒镇静效果。
在三个 DBS 中心的 38 例手术（74 个 MER 轨迹，5962 个记录部位）中，回顾性比较了三种麻醉方案：1）异丙酚-氯胺酮（PK）间歇性麻醉，2）异丙酚-清醒间歇性麻醉（PA），和 3）完全清醒（AA）。
所有麻醉方案均能获得满意的 MER。专家组对 STN 边界和亚区的检测结果在各组间相似。氯胺酮下 STN 的电生理特征并不逊于对照组。所有患者均完成了刺激测试。
本研究支持 DBS 中使用小剂量氯胺酮麻醉方案，该方案下的微电极记录和刺激测试与清醒和异丙酚-清醒方案相当，且可能优化患者体验。应进行前瞻性、双盲研究，比较患者满意度和临床结局，以进一步证实这些发现。
