Table 2.
Postoperative stimulation induced urgencies and emergencies
| Issue | Routine/urgent/emergent | Management |
|---|---|---|
| Chorea/ballism | Routine/urgent | Try to program slowly (e.g. slow increase of voltage over many weeks/months). May try dorsal contact. May also reduce dopaminergic medications. |
| Dyskinesia | Routine/urgent | Reducing the dopaminergic medication may help. Try to program slowly (e.g. slow increase of voltage over many weeks/months). May try dorsal contact. |
| Motor pulling | Urgent | Try to reduce voltage or pulse width. Try bipolar stimulation, or possibly another lead contact. Some situations may require lead replacement. Check lead location. |
| Gait disturbance | Routine/urgent | Try another setting (e.g. another contact, reducing pulse width, voltage or frequency). Low frequency (60Hz) with higher voltage or pulse width may help. |
| Verbal fluency problem | Routine | Try another contact, perhaps a more dorsal contact on the DBS lead. Try changing stimulation to bipolar or decrease pulse width, voltage or frequency. |
| Dysarthria/dysphagia | Routine | Try another contact. Try changing stimulation to bipolar or decrease pulse width, voltage or frequency. Check lead location. Prescribe speech therapy. |
| Hypophonia | Routine | Try another contact. Try changing stimulation to bipolar or decrease pulse width, voltage or frequency. Prescribe speech therapy. |
| Cognitive decline | Routine | This problem may be disease progression, surgery-related, or stimulation-related. Seek neuropsychological testing, consider reprogramming to a dorsal contact. Check lead location. |
| Mania/hypomania | Routine/urgent | Adjust medications. Consider discontinuation of dopamine agonist and use of clozapine or quetiapine. Consider moving to a dorsal contact and/or decreasing the pulse width, voltage or frequency. Check lead location. Consider admission for multi/interdisciplinary management. |
| Impulse control | Urgent | Adjust medications. Consider discontinuation of dopamine agonist and addition of clozapine or quetiapine. Consider moving to a dorsal contact and/or decreasing the pulse width, voltage or frequency. Check lead location. Consider admission for multi/interdisciplinary management. |
| Suicide ideation/attempt | Emergent | Admit the patient to the hospital for multi/interdisciplinary care, and treat underlying cause. May need both medication adjustment and programming. Check lead location. |
| Anxiety/fear | Urgent | Consider more frequent and higher doses of dopaminergics, and altering DBS contacts, perhaps moving more dorsal. Check lead location. Consider admission for multi/interdisciplinary management. |
| Severe depression | Emergent | Behavioral therapy, counseling, medication adjustment and/or stimulation adjustment. Check lead location. Consider admission for multi/interdisciplinary management. |
| Postoperative mania | Urgent | Behavioral therapy, counseling, medication adjustment and/or stimulation adjustment. Check lead location. Consider admission for multi/interdisciplinary management. |
| Pseudobulbar cry/laughter | Urgent | SSRI, TCA or dextromethorphan. |
| Autonomic features | Urgent | May habituate on own, try stimulation parameter adjustments, or change contact if continues to be troublesome. |
| Sensory phenomena | Urgent | Try reduce voltage or pulse width. Try bipolar, or possibly other contact. |
| Accidental on/off | Urgent/emergent | Turn on the IPG, keep a diary to identify the problem. |
| Symptom rebound (motor and/or non-motor) | Emergent | DBS hardware workup including impedance check, battery check, x-ray study, and assess for tolerance. |