- Department of Neurosurgery, University of Athens Medical School, “Evangelismos” Hospital, Athens Greece
- Hellenic Center for Neurosurgical Research, “P.Kokkalis”, Athens, Greece
- epartment of Neurology, 1st Hospital of Social Security Services, Athens, Greece
Marios S. Themistocleous
Department of Neurosurgery, University of Athens Medical School, “Evangelismos” Hospital, Athens Greece
Hellenic Center for Neurosurgical Research, “P.Kokkalis”, Athens, Greece
DOI:10.4103/2152-7806.78240Copyright: © 2011 Themistocleous MS This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Themistocleous MS, Boviatsis EJ, Stathis P, Stavrinou LC, Sakas DE. Infected internal pulse generator: Treatment without removal. Surg Neurol Int 23-Mar-2011;2:33
How to cite this URL: Themistocleous MS, Boviatsis EJ, Stathis P, Stavrinou LC, Sakas DE. Infected internal pulse generator: Treatment without removal. Surg Neurol Int 23-Mar-2011;2:33. Available from: http://sni.wpengine.com/surgicalint_articles/infected-internal-pulse-generator-treatment-without-removal/
Background:One of the rare but devastating complications of deep brain stimulation (DBS) is internal pulse generator (IPG) infection. In the majority of the cases, removal of the device is required, despite appropriate antibiotic therapy. We demonstrate that eradication of an IPG infection is feasible without removal of the IPG device.
Case Description:This article reports the authors’ experience on two patients who underwent DBS for advanced Parkinson's disease (PD) and, subsequently, suffered from infection and skin breakdown over the IPG. The patients were treated with antibiotic therapy, surgical revision of the wound, intraoperative disinfection of the IPG and relocation of the subcutaneous pocket. In both cases, the infection was eradicated and DBS therapy was continued uninterrupted.
Conclusion:Although not generally recommended, DBS IPG may be salvaged in selected cases of superficial device infection. Our experience suggests that it is possible to treat the infection without removing the device. Such an approach decreases the morbidity, duration of hospital stay and health care costs.
Keywords: Deep brain stimulation, infection, internal pulse generator, Parkinson's disease
Deep brain stimulation (DBS) is an effective form of treatment for an increasing number of patients with movement disorders and pain. It is a reversible procedure and its effect is based on an electrical modulation of the nervous system. Even though technological advances have improved the efficacy and safety of this procedure, there may be different hardware-related complications.[
The hardware-related infection rates may be as high as 12.2%,[
We describe our experience with two patients who developed wound infection and explantation of the IPG. They were successfully treated with IPG disinfection, systemic antibiotic treatment, revision of the surgical wound and relocation of the device. To the best of our knowledge, the treatment of the externalization of the IPG through skin breakdown, without replacing the device, has not been reported previously.
The first patient was a 54-year-old male with a 12-year history of Parkinson's disease (PD). The patient underwent bilateral subthalamic nucleus (STN) DBS surgery according to our standard protocol in 2003.[
The second patient was a 67-year-old female with a 20-year history of PD. She underwent bilateral DBS electrode (Medtronic electrode 3389, Minneapolis, MN, USA) implantation in the STN. The IPG (Kinetra, Medtronic) was implanted in a subclavicular subcutaneous pocket. Four weeks later, she presented with explantation of the IPG [
We concluded that it was worthwhile to try to preserve the IPG. Hence, both patients underwent surgical exploration of the subclavicular wound under general anesthesia. The IPG was removed from the subcutaneous pocket and disconnected from the lead extender. The scar behind the ear was explored and the lead extender was disconnected from the DBS electrode and removed. The IPG was meticulously cleaned and disinfected with the use of aqueous povidone-iodine and a vancomycin solution (1 g in 500 ml of NaCl 0.9%). The IPG was initially scrubbed for 10 min using the aqueous povidone-iodine solution and subsequently soaked in the vancomycin solution for another 20 min. Cultures taken from the IPG at this point were negative. The device was then repositioned in a new subcutaneous pocket fashioned superficial to the rectus sheath, under the right hypochondrial arc, opposite to the site of the original placement. A new lead extender was then tunneled under the scalp and attached to the DBS leads proximally and to the IPG distally. The wounds were sutured and the stitches were removed on the 10th postoperative day. Intraoperative vancomycin was administered and the antibiotic treatment was continued for a period of 2 weeks. At the 6-month and 1-year follow-up examinations, both patients showed no signs of local infection.
DBS involves implantation of electrodes and pulse generators, thereby introducing potential hardware-related adverse effects, with infection rates requiring removal of the IPG varying from 0.7 to 3.7%.[
Factors probably related to the infection rate include surgical technique, length of the procedure, antibiotic prophylaxis[
IPG infections are usually caused by organisms of low virulence. Much like the cardiac pacemaker – a device very similar to the IPG – the microorganisms most frequently implicated are the coagulase-negative Staphylococci.[
Usually, Staphylococcal infections of the implantable material require replacement of the device. Some nonadherent bacteria that are unable to produce this slime are more likely to respond to treatment by antibiotics alone without the removal of the colonized device.[
To the best of our knowledge, there are no previous reports in the literature of IPG infection, skin breakdown and exposure to the air that have been treated successfully without replacing the device. In all previously reported cases, the treatment of this problem required the removal of the IPG and its replacement after a considerable period of time.[
Although not generally recommended, DBS IPG may be salvaged in selected cases of superficial device infection. Our experience suggests that it is possible to treat infection without removing the device.
Our experience indicates that if the treatment is offered promptly, according to our protocol, it is possible to treat infection without removing the device. With this approach, the patients may be spared of DBS therapy interruptions and additional procedures for IPG replacement. In addition, health care insurers will not be asked to cover the increased costs for this type of therapy.
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