CASE REPORT

Deep brain stimulation and intracerebral infection:A case report and review of the literaturePeter Zsigmond and Nathanael G€oransson

Department of Neurosurgery, Link€oping University, Link€oping, Sweden

Key words

deep brain stimulation, intracerebral infection,

movement disorders, Parkinson’s disease.

Accepted for publication 4 July 2014.

Correspondence

Peter Zsigmond

Department of Neurosurgery and Department

of Clinical and Experimental Medicine,

Link€oping University, S-581 85 Link€oping,

Sweden.

Email: peter.zsigmond@lio.se

Abstract

Deep brain stimulation is a well-established surgical treatment for patients withmovement disorders. Adverse events, such as hardware infections, are well known,

but intracerebral infections are extremely rare, and can develop both shortly aftersurgery and after several months. We present one case of intracerebral infectionafter deep brain stimulation surgery, and a short review of the literature.

Introduction

Deep brain stimulation (DBS) is today a routine surgical

treatment for various advanced neurological disorders, suchas Parkinson’s disease, essential tremor and dyskinesia.Stimulation-induced side-effects and complications associ-

ated with this technique are well known and analyzed indifferent studies. One of the most common complications ishardware-related infections. When reviewing published stud-

ies regarding DBS and infections, most are related to thehardware, and very seldom to the brain tissue itself. To ourknowledge, there are just six intracerebral infections after

DBS surgery described in the literature.1–3 Previously, Blom-stedt reviewed 20 publications of over 3800 patients focusingon complications of DBS surgery without a single case ofintracerebral infection reported.1 Hardware-related infection

is a well known and common side-effect, but intracerebralinfection after DBS surgery seems to be an extremely rare,but serious, complication.

Case Report

We present one case of intracerebral infection after DBSsurgery for Parkinson’s disease. In our practice, we havetreated 190 patients with DBS since 15 years. Two surgeons

carried out the operations.The patient was a 59-year-old man who had been diag-

nosed with Parkinson’s disease 9 years earlier. He had no his-tory of scalp or skin acne. He was considered eligible for

subthalamic DBS due to wearing off phenomena and severelevodopa-induced dyskinesias. The surgical procedure wascarried out in one single theater session without externalizing

the electrodes. Prophylactic antibiotics, 2 g of cloxacillin,

were given intravenously as a single dose. A computedtomography scan was carried out 2 days postoperatively forconfirming electrode localization in SurgiPlan (Leksell Surgi-

Plan System; Elekta, Stockholm, Sweden). There were nosigns of edema in the computed tomography images and noother pathology was shown. The patient recovered well and

was discharged after 4 days without complaints. Ten dayspostoperatively he was admitted to hospital due to confusion,fever and an elevated C-reactive protein (CRP; 117 g/L).

Computed tomography and magnetic resonance imaging(MRI) showed edema along the left implanted intracerebrallead. The whole system was removed, and perioperative

bacterial cultures were taken and showed Propionibacteriumacnes from the electrode tip and burrhole. The other cultureswere negative. The patient recovered with normalized cogni-tive function and decreasing C-reactive protein within

1–2 days. After 2 weeks, MRI showed no signs of infection oredema, as seen in Figure 1. The patient was treated with anti-biotics for 2 weeks postoperatively. The patient was sched-

uled for new DBS surgery 4 months after the initial surgery.

Discussion

To our knowledge, there are just six cases of intracerebralinfections after DBS surgery reported in the literature. In

2008, Videnovic and Metman reviewed the prevalence ofadverse events in 1154 patients with DBS, where theyreported that 2.4% of the patients had hardware-relatedinfections, but none with intracerebral infection.4 The case

described by Merello in 2001 is interesting, as the symptomsof infection were described several months after surgery. Allcases described in the literature showed different bacterial

cultures. Even though the histories of Propionibacterium

Neurology and Clinical Neuroscience 2 (2014) 161–162 161

ª 2014 Japanese Society of Neurology and Wiley Publishing Asia Pty Ltd

doi:10.1111/ncn3.111

acnes infection were slower and not as aggressive as in thepresent case, this was the only positive bacterial growth.Most likely this represents a perioperative electrode infection.

Deligny et al. described a case where the infectious symptomsappeared after 40 days, and as the patient already had goodeffect of stimulation, they carried out subthalamotomy using

the DBS lead with good postoperative outcome. In the pres-ent case, this was not an option, as the stimulation was neverstarted and no adjustments had been made in the medical

therapy. Even though intracerebral infections after DBS sur-gery are extremely rare, its existence as a very serious compli-cation should be kept in mind as a differential diagnosiswhen symptoms appear shortly after surgery, but also when

symptoms appear after a longer time. Differential diagnosisshortly after surgery can be intracerebral hematoma or hyg-roma, and if the symptoms appear after several weeks with

the stimulator on, it is easy to misinterpret them as due tostimulation side-effects, especially if no fever is present. Ra-mirez-Zamora recently presented two cases of intraparenchy-

mal cysts after DBS surgery. This is also a rare complicationthat can be clinically difficult to differentiate from delayedintracerebral electrode infection.5 The best radiological fol-low up for diagnosis of abscess or edema along the electrodes

is MRI, which can be safely carried out with the stimulatoroff in a 1.5 T camera. Edema along the implanted electrodeis rare, and if present, intraparenchymal infection should be

kept in mind. A rare complication could also be an allergicreaction to the electrode materials, this could cause a hyper-intensity area around the electrode in T2-weighted MRI

images. During implantation in our practice, we touch the

electrode with new gloves, a more meticulous handling wouldbe to only touch the electrode with new clean forceps. In con-clusion, intracerebral infections after DBS surgery is very

rare, can develop both shortly and delayed after surgery, anddifferent differential diagnosis should be kept in mind. Anintracerebral infection could be one of the diagnoses after

surgery if the patient presents with fever, elevated CRP andnew neurological symptoms. Patients with suspected intrace-rebral infection should be scanned with MRI, as edema along

the electrode is best visualized.

References

1 Blomstedt P, Bjartmarz H. Intracerebral infections as a

complication of deep brain stimulation. Stereotact. Funct.

Neurosurg. 2012; 90: 92–96.2 Deligny C, Drapier S, Verin M, Lajat Y, Raoul S, Damier P.

Bilateral subthalamotomy through DBS electrodes: A rescue

option for device-related infection. Neurology 2009; 73:

1243–4.3 Merello M, Cammarota A, Leiguarda R, Pikielny R. Delayed

intracerebral electrode infection after bilateral STN implantation

for Parkinson’s disease. Mov. Disord. 2001; 16: 168–70.4 Videnovic A, Verhagen Metman L. Deep brain stimulation

for Parkinson’s disease: Prevalence of adverse events and

need for standardized reporting. Mov. Disord. 2007; 23:

343–9.5 Ramirez-Zamora A, Levine D, Sommer DB, Dalfino J,

Novak P, Pilitsis JG. Intraparenchymal cyst development after

deep brain stimulator placement. Stereotact. Funct. Neurosurg.

2013; 91: 338–41.

(a) (b) (c)

Figure 1 (a) Computed tomography scan with contrast enhancement 10 days after surgery with magnificent edema surrounding the left

intracranial electrode. (b) Magnetic resonance imaging 2 days after removal of electrodes showed remaining edema along the electrode tract. (c)

Magnetic resonance imaging 10 days after electrode removal shows almost normal findings. The patient was in his habitual status.

162 Neurology and Clinical Neuroscience 2 (2014) 161–162

ª 2014 Japanese Society of Neurology and Wiley Publishing Asia Pty Ltd

DBS and intracerebral infection P Zsigmond and N G€oransson