Description of Event or Problem · 1
LITERATURE: SERVELLO D, SASSI M, BASTIANELLO S, POLONI GU, MANCINI F, PACCHETTI C. ELECTRODE DISPLACEMENT AFTER INTRACEREBRAL HEMATOMA AS A COMPLICATION OF A DEEP BRAIN STIMULATION PROCEDURE. NEUROPSYCHIATR DIS TREAT. 2009; 5: 183-187. SUMMARY: IN 2006, IMMEDIATE POSTOPERATIVE NEUROLOGICAL STATUS OF THE PATIENT WAS FOLLOWED AT THE NEUROSURGICAL WARD AND WAS NEGATIVE. FOUR HOURS AFTER SURGERY, THE PATIENT UNDERWENT A CONTROL CT SCAN OF THE BRAIN DOCUMENTING CORRECT POSITIONING OF THE STIMULATING ELECTRODES. A MINIMAL (LESS THAN 0.5 CM) CORTICAL HEMATOMA ON THE LEFT SIDE WITH NO MASS EFFECT WAS DOCUMENTED. ONE HOUR LATER, RIGHT HEMIPARESIS AND DIMINISHED LEVEL OF CONSCIOUSNESS WERE NOTICED, TOGETHER WITH A SEVERE DYSARTHRIA. A CT SCAN WAS OBTAINED AND A 3CM MAXIMUM DIAMETER CORTICAL-SUBCORTICAL HEMATOMA WAS DOCUMENTED, APPROXIMATELY 25 CC IN VOLUME, LOCATED IN THE FRONTAL LOBE ALONG THE ELECTRODE'S TRAJECTORY, WITH A SIGNIFICANT LOCAL MASS-EFFECT. AFTER CAREFUL DISCUSSION CONSIDERING THE ABSENCE OF MIDLINE SHIFT, AND THE ABSENCE OF A FURTHER WORSENING OF THE CLINICAL PICTURE, CONSERVATIVE MANAGEMENT WAS DECIDED UPON, AND WAS MAINLY BASED ON THE STABILITY OF THE CLINICAL PICTURE OF THE PATIENT. THE NEUROLOGICAL STATUS OF THE PATIENT SLOWLY IMPROVED OVER THE FOLLOWING DAYS, AND NO INTENSIVE CARE ADMISSION WAS REQUIRED. AT A CT SCAN PERFORMED EIGHT DAYS AFTER STN-DBS, INITIAL LATERAL DISPLACEMENT OF THE LEFT ELECTRODE WAS NOTICED, AND REACHED 8 MM LATERAL TO THE TARGET AS MEASURED ON THE AXIAL PLANE AT A CT SCAN CONTROL PERFORMED DURING THE 13TH POSTOPERATIVE DAY. THE PATIENT WAS DISMISSED FROM THE NEUROSURGICAL WARD AND SENT TO THE NEUROLOGY DEPARTMENT ONE MONTH LATER, AFTER A SECOND SURGICAL PROCEDURE FOR POSITIONING OF THE IMPLANTABLE NEUROSTIMULATOR (INS) IN A SUBCUTANEOUS, SUBCLAVEAR POUCH. THE INS WAS ACTIVATED 45 DAYS AFTER ELECTRODE IMPLANTATION, AFTER A CT SCAN HAD DEMONSTRATED A COMPLETE RE-ABSORPTION OF THE HEMATOMA. THE IMAGES FROM THIS CT SCAN WERE OBTAINED WITH AN INCLINATION OF THE GANTRY WHICH WAS DIFFERENT FROM THE IMMEDIATE POSTOPERATIVE CT CONTROL. TO ADDRESS THIS PROBLEM AND CORRECTLY EVALUATE THE POSITION OF THE LEFT ELECTRODE AFTER HEMATOMA RE-ABSORPTION, THE IMAGES WERE RE-CALCULATED WITH THE AID OF DEDICATED SOFTWARE. COMPARISON BETWEEN THE TWO EXAMS DOCUMENTED RETURN OF THE ELECTRODE TO A POSITION COMPARABLE TO THE IMMEDIATE POSTOPERATIVE CONTROL. THE PATIENT UNDERWENT AN INTENSIVE REHABILITATION PROGRAM, WITH PROGRESSIVE IMPROVEMENT OF THE RIGHT PYRAMIDAL SYNDROME, WHICH SIX MONTHS AFTER THE HEMORRHAGE, CONSISTED IN A SLIGHT HYPOSTENIA AT RIGHT LIMBS, SLIGHT DYSPHAGIA, AND SERIOUS DYSARTHRIA. AT THE EVALUATION PERFORMED SIX MONTHS AFTER SURGERY, THE PART II SCORE WAS 20 IN ON THERAPY/ON STIMULATION, 25 IN OFF THERAPY/ON STIMULATION, 22 IN ON THERAPY/OFF STIMULATION, AND 35 IN OFF THERAPY/OFF STIMULATION PHASE. THE EXAMINATION SCORE WAS 30 (RANGE 26/30). CLINICAL FEATURES WERE CHARACTERIZED BY SLIGHT HYPERTONIA AND HYPOKINESIA. THE SEVERE TRUNK DYSTONIA WAS REMITTED. THE ANTIPARKINSONIAN THERAPY CONSISTED IN LEVODOPA/BENSERAZIDE 150/37.5 MG FOUR TIMES A DAY AND 1 MG OF CABERGOLINE TWICE A DAY.