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CASE REPORT
Year : 2018  |  Volume : 13  |  Issue : 4  |  Page : 1276-1278

Venous infarct after sacrifice of single cortical vein during deep-brain stimulation surgery


Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy

Date of Web Publication23-Oct-2018

Correspondence Address:
Dr. Edvin Zekaj
Department of Neurosurgery, IRCCS Istituto Orthopedico Galeazzi, Milan
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_126_18

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  Abstract 


Intracerebral hemorrhage (ICH) is the most feared and dreadful complication related to deep-brain stimulation (DBS). Bleeding may originate from arterial or venous damage. Commonly, hemorrhage is detected by postoperative imaging performed to assess lead positioning in asymptomatic patients. Rarely, hemorrhage leads to stroke, coma, or even death. We present the case of a patient who suffered a severe ICH of venous origins after bilateral DBS. Deep-brain hemorrhages are the most difficult to be predicted and to be prevented because they are caused by small vessels. As superficial hemorrhages are secondary to venous coagulation or sulcal hemorrhage, neurosurgeons must drive all efforts to minimize their occurrence.

Keywords: Complications, deep-brain stimulation, hemorrhage, safety


How to cite this article:
Zekaj E, Saleh C, Ciuffi A, Franzini A, Servello D. Venous infarct after sacrifice of single cortical vein during deep-brain stimulation surgery. Asian J Neurosurg 2018;13:1276-8

How to cite this URL:
Zekaj E, Saleh C, Ciuffi A, Franzini A, Servello D. Venous infarct after sacrifice of single cortical vein during deep-brain stimulation surgery. Asian J Neurosurg [serial online] 2018 [cited 2018 Dec 17];13:1276-8. Available from: http://www.asianjns.org/text.asp?2018/13/4/1276/243730




  Introduction Top


Since its renaissance in 1987, deep-brain stimulation (DBS) is applied for pharmacological refractory movement disorders such as Parkinson's disease (PD), essential tremor, and dystonia[1],[2],[3],[4] and since 1999 for psychiatric disorders.[5] Surgical procedure consists in the unilateral or bilateral placement of DBS leads in basal ganglia structures. DBS is considered a relatively safe procedure. However, the most feared complication of DBS is intracerebral hemorrhage (ICH).[6] Incidence rates range between 0.5% and 5%, with 1.1% of cases resulting in permanent deficit or death.[7],[8] Venous infarction following DBS is rare.[9] We report and discuss a case of severe ICH secondary to venous infarction after DBS.


  Case Report Top


A 75-year-old woman with PD of 5 years' duration presented with right-sided arm and leg rigidity, right Pisa syndrome, and urinary urgency. After 3 years of symptom control by dopamine and dopaminergic therapy, she developed nocturnal motor blocks, dyskinesia, and progressive mental deterioration. In light of disease progression in spite of medical therapy, DBS of the subthalamic nucleus was considered. During the surgical procedure, performed with the patient awake, a cortical vein on the left side, which was at the borders of the burr hole, was sacrificed as it started bleeding [Figure 1] and [Figure 2]. The patient had no intraoperative symptoms. Postinterventional computed tomography (CT) scan showed correct lead positioning. Eight hours after the procedure, the patient developed aphasia and right hemiplegia. A brain CT scan showed a venous infarct with hemorrhagic conversion in the left frontal region with a large hypodense frontal area [Figure 3]. In cardiorespiratory stable state, the patient was transferred to the Intensive Care Unit for observation. The morning after, she deteriorated further with the Glasgow Coma Scale score dropping from 12 to 7. Prompt CT scan [Figure 4] evidenced a further enlargement of the hemorrhage with mass effect and midline shift not present on the previous scan. An emergency hemorrhage evacuation with left lead removal was performed. The postoperative CT scan showed a complete clot removal and reduced mass effect [Figure 5]. Clinical status remained however unchanged for the severe right-sided hemiparesis and aphasia. Subsequent rehabilitation helped to improve foremost the lower limb, and aphasia persisted.
Figure 1: Schematic drawing of patient's cortical venous anatomy. The red arrow indicates the cortical projection of the burr hole

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Figure 2: Operative view of the burr hole overlying the large frontal draining vein

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Figure 3: Hypodensity with hemorrhagic conversion in the left frontal lobe

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Figure 4: Massive frontal hemorrhagic conversion with mass effect

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Figure 5: Postsurgical image shows hemorrhage evacuation with reduction in mass effect

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  Discussion Top


Since the pioneering work of Benabid et al.[1] in the late 1980s, DBS has become a widely applied therapy for pharmacological refractory motor disorders worldwide. Rapid technological development has allowed to reduce the complication rate. However, as any surgical intervention, DBS is associated with reported adverse effects, the most fearsome being hemorrhage.[6] Hemorrhage is classified as deep or superficial brain bleeds. Deep hemorrhagic lesions are usually secondary to damage of tiny vessels, thus more difficult to avoid. It seems that the number of micro-recording traces used increases the risk of this type of hemorrhage.[10] Superficial hemorrhages may be secondary to arteriosus origin like sulcal arterial bleeding or secondary to venous infarction after cortical vein coagulation. In order to reduce the incidence of hemorrhage during DBS, lead trajectory has to avoid cortical sulci, superficial cerebral veins, and ventricles.[11] In some cases, small superficial cerebral veins are sacrificed and if venous drainage is sufficient, there are no sequelae; however, venous infarction represents a serious hazard.[9] Morishita et al.[9] reported four symptomatic cases of venous infarction in a series of 500 patients (0.8% per lead and 1.3% per patient). Our patient developed a major venous hemorrhagic infarct following coagulation of a superficial convexity vein. The lead trajectory avoided sulci, ventricles, and the vein which was at the margins of the burr hole. Unfortunately, the vein started bleeding during the procedure, thus it was necessary to coagulate it. As described, the patient developed an important venous hemorrhagic infarct which required an urgent surgical intervention of hematoma evacuation. We analyzed the presurgical T1-volumetric contrast-enhanced magnetic resonance images and identified the course of the coagulated vein. It was noted that the vein originated from the anterior frontal lobe and had a long trajectory posteriorly to enter into the middle part of the sagittal sinus. On the left cerebral hemisphere, we noticed a fewer number of cortical veins with respect to the contralateral side. These findings explain the severity of venous infarct after sacrification of a single venous vessel.


  Conclusion Top


Functional surgeons should be aware that superficial venous sacrifice needs to be strictly avoided as severe complication such as a venous infarct may result. This complication is more serious if cerebral venous circulation is less pronounced consequently with a less likely efficient venous collateral circulation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Benabid AL, Pollak P, Louveau A, Henry S, de Rougemont J. Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease. Appl Neurophysiol 1987;50:344-6.  Back to cited text no. 1
    
2.
Benabid AL, Pollak P, Gervason C, Hoffmann D, Gao DM, Hommel M, et al. Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet 1991;337:403-6.  Back to cited text no. 2
    
3.
Pollak P, Benabid AL, Gross C, Gao DM, Laurent A, Benazzouz A, et al. Effects of the stimulation of the subthalamic nucleus in Parkinson disease. Rev Neurol (Paris) 1993;149:175-6.  Back to cited text no. 3
    
4.
Blomstedt P, Hariz MI. Deep brain stimulation for movement disorders before DBS for movement disorders. Parkinsonism Relat Disord 2010;16:429-33.  Back to cited text no. 4
    
5.
Hariz MI, Blomstedt P, Zrinzo L. Deep brain stimulation between 1947 and 1987: The untold story. Neurosurg Focus 2010;29:E1.  Back to cited text no. 5
    
6.
Zrinzo L, Foltynie T, Limousin P, Hariz MI. Reducing hemorrhagic complications in functional neurosurgery: A large case series and systematic literature review. J Neurosurg 2012;116:84-94.  Back to cited text no. 6
    
7.
Fenoy AJ, Simpson RK Jr. Risks of common complications in deep brain stimulation surgery: Management and avoidance. J Neurosurg 2014;120:132-9.  Back to cited text no. 7
    
8.
Hariz MI. Complications of deep brain stimulation surgery. Mov Disord 2002;17 Suppl 3:S162-6.  Back to cited text no. 8
    
9.
Morishita T, Okun MS, Burdick A, Jacobson CE 4th, Foote KD. Cerebral venous infarction: A potentially avoidable complication of deep brain stimulation surgery. Neuromodulation 2013;16:407-13.  Back to cited text no. 9
    
10.
Hariz MI. Safety and risk of microelectrode recording in surgery for movement disorders. Stereotact Funct Neurosurg 2002;78:146-57.  Back to cited text no. 10
    
11.
Zrinzo L, van Hulzen AL, Gorgulho AA, Limousin P, Staal MJ, De Salles AA, et al. Avoiding the ventricle: A simple step to improve accuracy of anatomical targeting during deep brain stimulation. J Neurosurg 2009;110:1283-90.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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