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Deep Brain Stimulation Side Effects, Complications, and Risks

Deep Brain Stimulation Side Effects, Complications, and Risks

There are 22 Deep Brain Stimulation side effects and 14 Deep Brain stimulation complications, each varying in severity and prevalence. Most side effects are caused by stimulation and can be grouped into categories such as psychiatric or movement-related side effects. DBS complications can be separated into two groups; device-related and surgery-related complications. Research indicates DBS doesn’t lead to cognitive decline, hormonal disruptions, or sleep issues.

As our primary source for this list, we used the book Deep Brain Stimulation Management edited by William J. Marks, Jr.

Here are some key points from the article:

  • The most common side effects of Deep Brain Stimulation are depression, anxiety, and weight gain.

  • Almost all side effects of Deep Brain Stimulation can be treated by changing stimulation settings.

  • The most common complication of Deep Brain Stimulation is post-surgery confusion. 

  • The mortality rate of Deep Brain Stimulation is 0.26%.
Deep Brain Stimulation Side Effects And Complications

What are Deep Brain Stimulation side effects?

There are 22 Deep Brain Stimulation side effects. Below, these side effects are explained in detail, with prevalence, whether they’re more common in the Subthalamic Nucleus (STN) Globus Pallidus internus (GPi) or Ventralis Intermediate Vucleus of the thalamus (VIM) DBS, duration, permanency, causes, symptoms, diagnosis, and treatment strategies. Understanding these side effects is crucial for patients and healthcare providers to make informed decisions and manage the outcomes of DBS effectively.

Speech difficulties

Speech difficulties after DBS include dysarthria (pronunciation difficulty), dysphonia (abnormal voice), and hypophonia (soft voice due to muscle control issues). Dysarthria is prevalent in 5% to 25% of VIM DBS cases, while dysphonia and hypophonia are more common in STN DBS (4% to 17%) and can also occur with GPi DBS.

Speech issues are diagnosed by testing speech with stimulation on and off. Persistent speech problems when stimulation is off may signal disease progression. If issues worsen when the stimulation is on, adjusting stimulation parameters is necessary. After adjusting the stimulation, speech therapy is recommended. In some cases, patients may choose to temporarily turn off stimulation when speaking to improve clarity.

Dysphagia 

Dysphagia, or difficulty swallowing, occurs in 4% to 8% of patients with DBS in the STN. It’s unclear if dysphagia is caused by disease progression or by DBS, but it’s suspected it might be due to stimulation spreading to unintended areas in the brain

Symptoms include pain while swallowing, feeling like something is stuck in the throat, inability to swallow, and drooling. Diagnosis involves testing the ability to swallow with stimulation on and off. Dysphagia can be treated by adjusting stimulation parameters and medication dosages, swallowing therapy to prevent aspiration, and dietary adjustments with a dietician’s guidance.

Sialorrhea

Sialorrhea, excessive drooling, is most common in patients with DBS in the STN. It’s not certain if sialorrhea is caused by DBS or disease progression, but it may get worse if the patient’s cognitive abilities decline.

Treatment of sialorrhea varies according to the severity of the condition. For mild cases, activities that stimulate swallowing, like chewing gum or candy, or sipping drinks throughout the day are recommended. Severe cases may require medications to reduce saliva production or botox treatments.

Bladder function issues

Bladder function issues after DBS may include frequent nighttime urination, urgent daytime urination, and constipation. Urinary problems are common non-motor symptoms of Parkinson’s, and DBS can either improve or worsen these functions. Worsening is more associated with DBS in the STN.

Patients experiencing urinary issues post-DBS should undergo tests, possibly with a urology specialist. In cases of inability to empty the bladder, temporary or long-term catheter use may be necessary. For male patients, difficulty in bladder emptying after DBS could indicate an enlarged prostate and should be taken seriously.

Hypersexuality

Hypersexuality, characterized by uncontrollable sexual urges, fantasies, and actions, occurs in 2.4% of patients after DBS of the STN and is more prevalent in male patients under 60.

Doctors need to determine if hypersexuality is related to impulse control disorders (ICD) or if it is caused by stimulation. Management includes adjusting stimulation parameters and medications. In severe cases, psychiatric medications are used for symptom reduction.

Impulse control disorders (ICD)

Impulse control disorders (ICDs), characterized by an inability to control impulses, can manifest after DBS in the STN as uncontrolled urges related to sexuality, gambling, shopping, binge eating, and hoarding. Impulse control problems are linked to dopamine dysregulation after DBS.

Close monitoring after surgery is crucial for early symptom detection. Treatment involves adjusting stimulation parameters, altering Parkinson’s medication dosage, or using psychiatric medications.

Hypomania

Hypomania is a less severe form of mania with high mood and energy levels, sometimes leading to impulsive behavior. It has a prevalence of 4% to 15% after DBS of the STN. Hypomania can be treated by adjusting Parkinson’s medication dosages, Cognitive Behavioral Therapy, and psychiatric medication.

Depression

Depression, a common side effect of DBS in the STN, affects 1.5% to 25% of patients and decreases in severity over time. Depression can recur in patients even after receiving treatment before surgery.

Causes of depression include disease progression, dissatisfaction with surgery results, inadequate support from family and friends, lowered medication doses, or stimulation affecting unintended brain areas. Treatment involves adjusting stimulation parameters and medication dosages, and potentially, antidepressant therapy under psychiatric guidance.

Apathy

Apathy is another common side effect, affecting 4% to 25% of patients after DBS of the STN. Apathy is more common in patients who had fluctuations in non-motor symptoms before surgery. Apathy can present with or without depression. 

Suicide attempt

Suicide attempts post-DBS are rare, with a prevalence of 0.5% to 2.9%. Patients should be closely monitored for psychiatric conditions like depression, apathy, and impulse control issues that could lead to an attempt. Preventative measures are crucial, with help from a psychiatrist. In cases of suicidal ideation, inpatient treatment, and monitoring may be necessary.

Anxiety

Anxiety is the most prevalent symptom after STN DBS. Up to 75% of Parkinson’s patients can have anxiety before surgery. The severity of anxiety typically decreases as patients adjust to the stimulation.

Anxiety may accompany other symptoms like depression or panic attacks. Cognitive Behavioral Therapy is recommended for treatment, and psychiatric medications may be necessary in more severe cases.

Psychosis and hallucinations

Psychosis and hallucinations occur in 11% and 16% of patients, respectively, after DBS of the STN. Treatment may involve hospitalization for safety during medication and stimulation dose adjustments, and the use of antipsychotic medications that don’t exacerbate Parkinson’s symptoms.

Vision impairments

Visual impairments following DBS can include phosphenes (seeing sparkles of light), bilateral vision loss, eyelid apraxia (inability to open eyes), abnormal eye movements, and diplopia (double vision). STN DBS commonly causes double vision, abnormal eye movements, and eyelid apraxia, while GPi DBS is more linked to phosphenes and vision loss.

Abnormal eye movements and double vision often result from stimulation reaching unintended brain areas, causing symptoms like dizziness. These are usually treatable by adjusting stimulation settings.

Eyelid apraxia, with a 5% prevalence, often accompanies significant motor symptom reduction, making stimulation adjustment less effective. In such cases, botox injections every 3-6 months are recommended.

Visual phenomena like phosphenes and vision loss are rare and more typical post-ablation surgery. Experiencing post-surgery visual phenomena usually indicates stroke or hemorrhage, and can be resolved by adjusting stimulation parameters.

Dyskinesia and Hemiballismus

Dyskinesia, characterized by uncontrolled involuntary movements, and hemiballismus, involving painful movements on one side of the body, indicate a well-placed lead in STN DBS. These symptoms can emerge minutes to hours after stimulation begins or is increased.

Treatment involves adjusting stimulation parameters and reducing medication dosages, which is the intended result of DBS. Persistent dyskinesia despite these adjustments may suggest the need for lead replacement surgery in a different brain area

Muscle contraction

Muscle contractions as a side effect occur with DBS placements in the VIM, STN, and GPi. These contractions result from stimulation reaching unintended areas in the brain.

It’s crucial to determine that muscle contractions are caused by stimulation, not the underlying disease. Reprogramming the stimulation parameters can alleviate this side effect.

Status dystonicus

Status dystonicus can occur in dystonic patients who had GPi DBS when the device suddenly stops working, or when stimulation parameters are changed abruptly. The sudden stop or change causes severe muscle contractions all over the body. To avoid this, stimulation parameters should be changed slowly over time. 

Parkinsonism Hyperpyrexia Syndrome

Parkinsonism Hyperpyrexia Syndrome, or DBS withdrawal, is a rare but potentially fatal side effect with only a few reported cases. DBS withdrawal can occur if stimulation and/or medication is abruptly stopped.

DBS withdrawal symptoms resemble neuroleptic malignant syndrome and include fever, autonomic nervous system dysfunction, altered consciousness, rigidity, and elevated serum creatine phosphokinase, potentially leading to kidney failure.

Prevention involves close collaboration between patients and doctors to maintain medication regimens and monitor battery lifespan.

Gait impairment

Gait impairments do not respond well to DBS treatment, and can even get worse after DBS surgery in some cases. After surgery, patients can improve their gait with physical and occupational therapy. If it’s discovered that stimulation is worsening the gait, stimulation settings and medications are adjusted.

Postural instability and Ataxia

Postural instability and Ataxia, clumsiness and balance issues, are most common in patients who had DBS of the VIM for essential tremor, but they can also present in other placements and diseases. They have a prevalence of 3% to 7% and are usually reversible with adjustments to stimulation parameters.

Tachycardia

Tachycardia, an increase in heart rate to over 100 beats per minute, is common after STN DBS, affecting about 48% of patients. Up to 88% of patients may experience increased heart rate when stimulation is activated.

Tachycardia typically resolves within the first year post-surgery. It can affect blood pressure and should be closely monitored, especially in patients with cardiovascular disease history. Treatment ranges from increased water intake to medication, depending on severity.

Paresthesia

Paresthesia, characterized by skin sensations like prickling, burning, numbness, or tingling, occurs in 10% of patients post-DBS in the STN or VIM and is usually temporary. It’s more common in patients requiring higher stimulation levels. Paresthesia occurs due to stimulation spreading to unintended areas in the brain and is typically resolved by adjusting stimulation parameters.

Weight gain

Weight gain is a common symptom of DBS, affecting 6% to 100% of patients with STN DBS and 26% to 96% with GPi DBS. Patients typically gain about 9 to 10 kilograms (19 to 22 lbs) in the first year post-surgery.

Causes include impulse control issues leading to binge eating, a decrease in tremors, and burning fewer calories, and lifestyle, diet, and exercise changes. To prevent rapid weight gain, counseling with a dietitian and a physical therapist-approved exercise program are recommended.

What are Deep Brain Stimulation complications?

There are 14 Deep Brain Stimulation complications, including device-related and surgery-related complications ranging from mild to severe. Below, we have explained them in detail, their prevalence, who’s more likely to develop these complications, and how they can be prevented or treated. 

Pain around neurostimulator

Pain around the neurostimulator device is common in thin patients, with a prevalence of 11% to 36%. Typically, doctors prescribe a cream to alleviate this pain. If the pain continues, relocating the neurostimulator to the abdomen is recommended.

Neurostimulator migration

Neurostimulator migration, where the device’s battery moves under the skin, occurs in 1% to 18% of patients, often in those with obesity or compulsive picking and twiddling habits. Migration can be confirmed with an X-ray. Neurostimulators should be repositioned and placed deeper in the skin if migrated.

Lead migration

Lead migration is a rare, long-term complication with a prevalence of 0.5%. It can be seen in patients with dystonic head movements, and children who received DBS and now their skull has grown. Lead migration can be detected with MRI or CT imaging. When it occurs, it can be compensated by reprogramming or might require surgery to reposition the lead.

Wire breakage

Wire breakage usually happens at the extension cable and the leads, and has a prevalence of 0.94% to 8.5% after surgery. Wire breakage is the most common among patients with essential tremor, dystonia, or Tourette’s who struggle with involuntary movements of the head and patients with picking or twiddling compulsions. 

When a wire breaks, patients can feel an electric shock sensation around the lead or the wire. Treatment involves surgery to replace the cables, and better secure them under the skin.

Neurostimulator battery running out

The battery of the neurostimulator running out is a common complication if the device is non-rechargeable, and stimulation settings are high. As the battery runs out, the patient will feel their symptoms worsening. To prevent this complication, battery capacity should be checked regularly, and replacements should be made without delay. 

Neurostimulator malfunction

Neurostimulator malfunction is rare with newer device models. At each programming visit, doctors should check if the device is working properly. Patients may experience a shocking sensation near the neurostimulator if it malfunctions.

Infection

Infection after DBS surgery occurs in 3% to 10% of cases, typically around the neurostimulator in the chest. Prevention involves using antibiotics for 2 weeks, minimizing the hospital stay, and meticulous wound care after surgery. If infection occurs, the device is temporarily removed and antibiotics are used for 2 months before re-implantation.

Skin erosion

Skin erosion, the gradual wearing down of skin layers, is a complication occurring in 0.6% to 6.5% of patients. Common in elderly individuals with fragile skin, it develops over time due to factors like bulky neurostimulators or tight sutures.

Symptoms include redness, tenderness, itching, scarring, and changes in skin texture and color. Treatment options range from skin revision to relocation of cables, depending on severity. It can be prevented by routine checkups of the surgery area during appointments. 

Sterile seroma

Sterile seroma, a buildup of clear fluid under the skin, is a temporary complication of DBS surgery. If not absorbed naturally by the body, a doctor can drain the fluid.

Seizure

Seizures after DBS surgery occur in 0.4% to 3.1% of patients, typically not for the long term. Seizures can be managed with medications for 3 to 6 months after surgery.

Post-op confusion

Post-op confusion, seen in 1% to 36% of patients, is typically temporary and can result from anesthesia, medication withdrawal, or preexisting conditions. Persistent confusion may indicate an underlying issue.

Stroke or Brain Bleed

After DBS, there is a rare chance of a stroke or a brain bleed. The type of stroke is called a Deep Cerebral Venous Infarction. It usually happens in conjunction with a brain bleed and has a prevalence of 0.9% to 2.3%. It’s treated with anticoagulant medications.

Brain bleeds can occur in the brain tissue, or between the brain and its protective outer layer. Brain bleeds after DBS have a prevalence of 1% to 5%, and is mostly seen in patients with high blood pressure.

Pulmonary Embolism

A pulmonary embolism is when a blood clot blocks blood flow to the lungs. Pulmonary embolism affects 0.4% to 4.9% of patients, with increased risk in Parkinson’s Disease patients due to limited mobility.

Symptoms include sudden shortness of breath, chest pain when breathing and coughing blood. Pulmonary embolism can be prevented by wearing compression garments. Treatment of embolism includes blood thinners.

Pneumonia

Pneumonia, fluid accumulation in the lungs, affects about 0.6% of patients within 30 days after surgery. It’s more common in Parkindon’s patients with preexisting swallowing issues. It’s treated with antibiotics.

 

What is the mortality rate of Deep Brain stimulation?

Deep Brain Stimulation mortality rate is 0.26%, with 0.15% of it being related to surgical factors according to the most comprehensive study on the subject from Maine Medical Center Neuroscience Institute.

Does Deep Brain Stimulation cause cognitive decline or dementia?

No, Deep Brain Stimulation does not cause cognitive decline or dementia according to research from CHU Grenoble Alpes University Hospital by Francesco Bove et al.

Does Deep Brain Stimulation affect hormone levels or cause endocrine issues?

We don’t know if Deep Brain Stimulation can affect hormones as there is not enough scientific literature looking at the effects of DBS on the endocrine system.

Is there a risk of skin irritation or allergic reactions at the DBS implant site?

Yes, there is a risk of skin irritation or allergic reactions at the implant site but it’s extremely rare with only 13 reported cases worldwide, according to a literature review by Austin Brown et al.

Can Deep Brain Stimulation cause more medication side effects?

No, Deep Brain Stimulation cannot cause more medication side effects. Deep Brain Stimulation of the STN is used to reduce medication intake, which in turn reduces medication side effects. However, if medication doses are adjusted after stimulation, side effects can be seen. 

How does Deep Brain Stimulation impact sleep?

Deep Brain Stimulation impacts sleep positively. Deep Brain Stimulation of the STN can improve sleep quality, decrease early morning and nighttime dystonia, and increase continuous sleep time and efficiency according to a literature review from the University of Alabama at Birmingham, Department of Neurology.

What are the benefits of Deep Brain Stimulation?

Deep Brain Stimulation reduces Parkinson’s related motor symptoms, like tremors, and decreases the need for medication, reducing drug side effects. It also helps alleviate psychiatric conditions such as depression, anxiety, and OCD, enhancing overall quality of life. It’s an effective solution for long-term symptom management. One of the key advantages of DBS is its reversibility and removability. As a non-invasive treatment option, it presents a lower risk compared to traditional surgical interventions.

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