Long-term deep brain stimulation in elderly patients with cardiac pacemakers

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Object. Deep brain stimulation (DBS) has become an accepted therapy for movement disorders such as Parkinson disease (PD) and essential tremor (ET), when these conditions are refractory to medical treatment. The presence of a cardiac pacemaker is still considered a contraindication for DBS in functional neurosurgery. The goal of this study was to evaluate the technical and clinical management of DBS for the treatment of movement disorders in elderly patients with cardiac pacemakers.

Methods. Six patients with cardiac pacemakers underwent clinical and cardiac examinations to analyze the safety of DBS in the treatment of movement disorders. Four patients suffered from advanced PD and two patients had ET. The mean age of these patients at surgery was 69.5 years (range 63–79 years). The settings of the pacemakers were programmed in a manner considered to minimize the chance of interference between the two systems.

There were no adverse events during surgery. Four patients underwent stimulation of the thalamic ventralis intermedius nucleus (VIM), and two patients stimulation of the subthalamic nucleus. In general, bipolar sensing was chosen for the cardiac pacemakers. In all but one patient the quadripolar DBS electrodes were programmed for bipolar stimulation. Several control electrocardiography studies, including 24-hour monitoring, did not show any interference between the two systems. At the time this paper was written the patients had been followed up for a mean of 25.3 months (range 4–48 months).

Conclusions. In certain conditions it is safe for patients with cardiac pacemakers to receive DBS for treatment of concomitant movement disorders. Cardiac pacemakers should not be viewed as a general contraindication for DBS in patients with movement disorders.

Article Information

Address reprint requests to: Joachim K. Krauss, M.D., Department of Neurosurgery, University Hospital, Klinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. email: joachim.krauss@nch.ma.uni-heidelberg.de.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Chest x-ray film obtained after the implantation of a cardiac pacemaker (on the right side) and an impulse generator (on the left side), which is connected to a quadripolar electrode in the left VIM to treat ET.

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    Case 2. Printout of ECG tracings obtained on examination of the cardiac pacemaker. The DBS device was programmed in the unipolar configuration, and the atrial lead sensing configuration is also unipolar. The surface ECG tracing shows major artifacts due to the unipolar DBS, and the intracardial ECG shows normal atrial sensing but artifacts at 130 Hz. Upper: Trace-marker channel. Center: Trace of surface ECG signals. Lower: Trace of intracardial ECG signals.

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    Case 2. Additional printout of ECG tracings obtained on an examination of the cardiac pacemaker. The DBS device was programmed in the unipolar configuration, but now the atrial lead sensing configuration is bipolar. The surface ECG tracing again showed major artifacts due to the unipolar DBS; the intracardial ECG tracing showed normal atrial sensing and now there are only minor artifacts. Upper: Trace-marker channel. Center: Trace of surface ECG signals. Lower: Trace of intracardial ECG signals.

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    Case 6. Printout of surface and intracardial ECG signals. Both DBS and cardiac pacemaker sensing are programmed in bipolar mode. There is no interference between the two systems. Upper: Trace of surface ECG signals. Center: Trace-marker channel. Lower: Trace of intracardial ECG signals (ventricular and atrial).

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