Introduction: Deep brain stimulation (DBS) hardware complications have been traditionally managed by removal of the entire system. Explantation of the system results in prolonged interruption to the patient’s care and potential challenges when considering reimplantation of the cranial leads. The purpose of this study was to understand whether complete explantation can be avoided for patients initially presenting with wound dehiscence and/or infection of hardware. Methods: We performed a retrospective study that included 30 cases of wound dehiscence or infection involving the DBS system. Patients underwent reoperation without explantation of the DBS system, with partial explanation, or with complete explantation as initial management of the complication. Results: A total of 17/30 cases were managed with hardware-sparing wound revisions. The majority presented with wound dehiscence (94%), with the scalp (n = 9) as the most common location. This was successful in 76.5% of patients (n = 13). Over 11/30 patients were managed with partial explantation. The complication was located at the generator (91%) or at the scalp (9%). Partial explantation was successful in 64% of patients (n = 7). In cases that underwent a lead-sparing approach, 33% of patients ultimately required removal of the intracranial lead, and 2/30 cases of hardware infection were managed initially with total explantation. Discussion/Conclusion: Wound dehiscence can be successfully managed without complete removal of the DBS system in most cases. In cases of infection, removing the involved component(s) and sparing the intracranial leads may be considered. Wound revision without removal of the entire DBS system is safe and can improve quality of life by preventing or shortening the withdrawal of DBS treatment.

Deep brain stimulation (DBS) is a safe and effective surgical option for management of a variety of disorders, particularly movement disorders including Parkinson’s disease and essential tremor. While the risk of major neurological complications is small, DBS hardware complications are relatively common. The incidence of any hardware complication has been cited at a wide range between 3.2 and 15% [1‒3]. Hardware-related complications include infection, wound dehiscence, electrode breakage, lead migration or misplacement, and stricture formation. In particular, infection and wound dehiscence resulting in exposure of the hardware have a reported rate up to 10.6 and 2.5%, respectively [1‒9].

Traditionally, these complications have been managed by removal of the entire DBS system, regardless of whether every component appears to be involved or not, due to the concern for infection seeding the hardware. The governing idea is that the body cannot clear the infection unless it is all removed. Some reports in the literature attempt to salvage a part of the DBS system in the face of these complications [1, 2, 4, 5, 10]. However, there is a limited understanding on how to best manage these hardware-related complications, and most are managed based on the surgeon’s training and/or personal anecdotal experience [4, 11].

Generally, hardware complications require surgical intervention. However, appropriate management may not require removal of the DBS system. In order to minimize interruption to DBS therapy, we attempted salvaging a part or the entire DBS system in cases of infection or wound dehiscence. Our objectives were to (1) analyze cases that required total, partial, and no explantation and (2) report on the outcomes of hardware-related complications that ultimately did not require explantation of the entire system.

This was an institutional review board-approved retrospective study. The study included all patients from January 2009 to December 2020. Charts were reviewed for patients with a history of DBS placement who presented with wound dehiscence (defined as the opening of a wound) or infection involving any part of the DBS system. All patients were operated at a single institution (Rutgers-Robert Wood Johnson University Hospital) by a single surgeon (the senior author). All cases were taken urgently to the operating room within 24 h of patient presentation to the emergency room. Patients underwent either total explantation (removal of the entire DBS system), partial explantation (removal of only a component of the DBS system), or wound revision without explantation (none of the DBS components were removed). A summary of our management algorithm is summarized in Figures 1 and 2. Patients were managed according to the algorithm shown, and any exceptions are elaborated further below. Intraoperative cultures were sent for all patients with purulent material identified. In cases where purulent material was not present, the decision to send intraoperative cultures was made by the senior surgeon. Infectious disease specialists were consulted to dictate antibiotic choice and duration based on the findings from intraoperative cultures. Patients without intraoperative cultures were discharged with cephalexin or clindamycin for 10–14 days. This was an empiric choice for these patients based on the most likely organisms involved.

Fig. 1.

Treatment algorithm for DBS wound dehiscence. DBS, deep brain stimulation.

Fig. 1.

Treatment algorithm for DBS wound dehiscence. DBS, deep brain stimulation.

Close modal
Fig. 2.

Treatment algorithm for DBS hardware infection. DBS, deep brain stimulation.

Fig. 2.

Treatment algorithm for DBS hardware infection. DBS, deep brain stimulation.

Close modal

Patients were placed into one of the 3 subgroups (without explantation, partial explantation, or total explantation) according to the initial management they underwent when they first presented. A subset of patients who underwent partial explantation was further classified as “lead-sparing” partial explantation where the DBS leads were not removed, while the generators with or without the extension wires were removed. Summary statistics were calculated via frequencies for categorical data and medians for continuous variables. All data analyses were performed using Microsoft Excel version 16.33.

Surgical Technique

For all patients, a linear incision was made at the cranial entry points in an AP direction that bisects the burr hole. The connector sites are left just lateral to the cranial incision. For patients that receive a dual-channel battery, both the connector sites are placed just laterally to the cranial incision. An intermediate incision is made behind the ear that is used to pass the extension wires to the chest (or up from the chest for Medtronic systems). It is not our routine to bury the connectors into the skull or bury the extension wires under the temporalis muscle behind the ear for naive cases. The generator was usually placed just superficial to the pectoralis fascia, except in cases where the patient was very thin. The decision to place the generator below the pectoralis was a judgment call made by the surgeon but was relatively infrequent.

There were 30 total complications, including 18 cases of wound dehiscence and 12 cases of infection. The majority of complications were located at the scalp or chest. Of these cases, 17 were managed without explantation, 11 were managed with partial explantation, and 2 underwent total explantation of the DBS system. The majority of cases were male (n = 21; 70%), and the median age was 57 years old (interquartile range [IQR] 46–65.8 years). The indications for DBS placement were Parkinson’s disease (n = 21; 70%), essential tremor (n = 5; 17%), refractory obsessive-compulsive disorder (n = 2; 6.7%), and dystonia (n = 2; 6.7%). The median time from Phase II DBS to reoperation for complication was 9.3 months (IQR 4–37.4 months). The median length of stay was 3 days (IQR days). Additional patient characteristics are summarized in Table 1.

Table 1.

Patient characteristics

 Patient characteristics
 Patient characteristics

Cases without Explantation of the DBS System

Patient Characteristics and Presentation

In total, 17 complications in 13 distinct patients were initially managed with wound revision and debridement. The majority of cases were male (n = 10; 59%). The median age was 49 years old (IQR 45–66 years). The indications for DBS placement were Parkinson’s disease (n = 10; 59%), essential tremor (n = 3, 17.7%), refractory obsessive-compulsive disorder (n = 2, 11.8%), and dystonia (n = 2, 11.8%). Additional patient characteristics are summarized in Table 1.

The median time from placement of the generator and extension wires (Phase II DBS) to reoperation was 11.5 months (IQR 4.9–40.7 months). However, 2 cases of wound dehiscence at the site of the generator presented after DBS generator battery replacement from battery depletion and not directly following the initial placement of the DBS system. Wound dehiscence without signs of infection (n = 11, 64.7%) was the most common complication. Five patients had both wound dehiscence and signs of infection (including erythema, tenderness, swelling, and/or warmth) without frank purulent material in the wound. Only 1 patient had infection (cerebral abscess) without dehiscence, resulting in seizures. The location of complication was at the scalp (n = 9), behind the ear (n = 5), at the chest (n = 2), or intracerebral (n = 1). In 4 cases, the patient reported a direct trauma to the site of dehiscence.

Operative Technique

Operative management was generally aimed at debridement of the wound and revision of the incision. In cases where the generator dehisced through the chest wall, the generator was repositioned and, in one case, reimplanted in a subpectoral pocket. In cases where the extension wire dehisced (most often along the skull or behind the ear), a trough was created along the skull, and the wire was ultimately moved and rerouted through this new trough. In 3 cases, a muscle flap was created and then rotated over the wire. In these cases, we created a temporalis muscle flap that was rotated over the hardware. The area was thoroughly irrigated, and any purulence was washed out in cases of infection. Vancomycin powder was used in all cases. Photographs of select revisions are shown in Figure 3, demonstrating exposure of DBS hardware.

Fig. 3.

a Cranial incision wound dehiscence after fall with head trauma. b Exposure of extension wire at posterior auricular incision. Both the cases managed were with wound revision and debridement.

Fig. 3.

a Cranial incision wound dehiscence after fall with head trauma. b Exposure of extension wire at posterior auricular incision. Both the cases managed were with wound revision and debridement.

Close modal

Postoperative Course and Outcomes

The median hospital length of stay was 1 day (IQR 1–3 days). All patients received a course of antibiotics postoperatively, regardless of the presence of infection. Cefalexin was the most commonly prescribed antibiotic overall. The patient with cerebral abscess required 8 weeks of IV ceftriaxone as intraoperative cultures grew back (Klebsiella pneumoniae).

Revision and washout of the wound without explantation of any part of the DBS system were successful in 76.5% of patients (n = 13). Of note, the patient with an intracerebral abscess was successfully managed without device removal, and the intracranial leads were never explanted. Six cases (35.3%) required reoperation for a second revision, and one case required a third revision which was ultimately successful. Three cases (17.6%) ultimately underwent reoperation to remove a part of the DBS system (generator and/or extension wire) without removal of the intracranial leads, due to infection (n = 2) or re-dehiscence of the wound (n = 1). In one case, the DBS intracranial lead was explanted due to infection of the scalp incision. The median time from the first reoperation to the second reoperation was 5.8 months (IQR 3.3–13.4 months). A time line of events from a selected sample cases is illustrated in Figure 4a–c.

Fig. 4.

Timeline of complications and operative management of selected sample cases with complicated clinical histories. a A patient with wound dehiscence initially managed with wound revision who ultimately required explantation. b A patient with wound dehiscence requiring a second wound revision. c A patient with wound dehiscence requiring 3 wound revisions. d A patient with wound infection managed with partial explantation, ultimately requiring removal of the ipsilateral DBS lead. DBS, deep brain stimulation.

Fig. 4.

Timeline of complications and operative management of selected sample cases with complicated clinical histories. a A patient with wound dehiscence initially managed with wound revision who ultimately required explantation. b A patient with wound dehiscence requiring a second wound revision. c A patient with wound dehiscence requiring 3 wound revisions. d A patient with wound infection managed with partial explantation, ultimately requiring removal of the ipsilateral DBS lead. DBS, deep brain stimulation.

Close modal

Partial Explantation of the DBS System

Patient Characteristics and Presentation

In total, 11 cases were managed with partial explanation of the DBS system. The majority of cases were male (n = 9; 81.8%). The median age was 57 years old (IQR 52–64 years). The indications for DBS placement were Parkinson’s disease (n = 9; 81.8%) and essential tremor (n = 2; 18.2%). Additional patient characteristics are summarized in Table 1.

The median time from placement of the generator and extension wires (Phase II DBS) to reoperation for complication was 6.5 months (IQR 2.8–33.8 months). The most common indication for partial explantation was infection (n = 9; 81.8%), all located in the chest. In the remaining 2 cases, the patient presented with wound dehiscence (18.2%), one at the chest incision and the other at the scalp incision. In total, the location of hardware complication was at the chest in 10 cases (90.9%) and at the scalp in 1 case (9.1%). Figure 5 demonstrates one case of infection at the generator. Although there was no obvious purulent material on gross examination of the patient, intraoperative wound exploration revealed pus surrounding the generator. This emphasizes the need for operative management as an underlying infection may not be immediately obvious on clinical examination of the patient. Consequently, in our practice, intraoperative findings drive the decision to remove hardware or not.

Fig. 5.

Generator infection managed with partial DBS explantation. DBS, deep brain stimulation.

Fig. 5.

Generator infection managed with partial DBS explantation. DBS, deep brain stimulation.

Close modal

Operative Technique

In 9 cases (81.8%), purulent material was identified intraoperatively, and cultures were sent for analysis. Any infectious tissue was removed, and the wound was thoroughly irrigated. The explanted components included the following: generator and extension wire (n = 6; 54.5%), generator only (n = 3; 33.3%), unilateral intracranial lead only (n = 1; 9.1%), and generator, extension wire, and unilateral intracranial lead (n = 1; 9.1%). In cases where the extension wires were not removed, the wires were irrigated and sutured into a pocket created away from the site of infection.

Postoperative Course and Outcomes

The median hospital length of stay was 3 days (IQR 3–4.5 days). All patients received antibiotics postoperatively and were discharged with appropriate antibiotics based on intraoperative culture results. Staphylococcus species was the most commonly isolated organism (n = 8, 72.7%).

In 8 cases, the explanted component was reimplanted at a later date. Reimplantation occurred at a median time of 4.0 months following explantation (IQR 3.4–6.2 months).

Overall, management with partial explantation was successful in 7 cases (63.6%). Of the 9 cases in which the intracranial lead was not initially explanted, revision of the wound with partial explantation was successful in 66.7% of patients (n = 6). The remaining 3 patients (33.3%) ultimately required explantation of the intracranial lead due to persistent infection. The median time from the first reoperation to explantation of the intracranial lead was 3.6 months (IQR: 3.1–27.6 months). A timeline of events from a selected sample case is illustrated in Figure 4d.

Complete Explantation of the DBS System

There were 2 cases of hardware complications that were managed with complete explantation of the DBS system. Both patients were male. Age was 61 and 68 years at the time of surgery in Case 1 and 2, respectively. Indication for DBS therapy was for Parkinson’s disease in both cases. Additional patient characteristics are summarized in Table 1.

The time from placement of the generator and extension wires (Phase II DBS) to reoperation for infection was 43.0 months and 3 months in Case 1 and 2, respectively. In one case, the patient presented with infection and wound dehiscence at unilateral scalp and posterior auricular incisions. In the second case, the patient presented with purulent drainage at bilateral scalp incisions (Fig. 6) with MRI concerning for intracerebral extension of the superficial infection.

Fig. 6.

Cranial incision infection with pus managed with total DBS explantation. DBS, deep brain stimulation.

Fig. 6.

Cranial incision infection with pus managed with total DBS explantation. DBS, deep brain stimulation.

Close modal

Intraoperative cultures from one case grew methicillin-sensitive Staphylococcus aureus (MSSA). Both methicillin-sensitive Staphylococcus aureus and Serratia mar­cescens grew in the second case. Both cases were additionally managed with IV ceftriaxone for 4 weeks. The hospital length of stay was 5 days and 4 days in Case 1 and 2, respectively.

In our series, surgical management of wound dehiscence and infection without removal of the entire DBS system was successful in the majority of cases. Preservation of the intracranial leads in appropriate cases allows for the patient to avoid undergoing a revision intracranial operation when revising the DBS system. A summary of our management algorithm is shown in Figures 1 and 2.

Wound Revision for Wound Dehiscence

In cases of wound dehiscence without purulence managed initially with wound revision and debridement only, 75% of cases were able to maintain their DBS therapy without additional interruption to their care. Four cases ultimately required partial explantation, and in only one case was a single intracranial lead removed.

In general, wound dehiscence is often not included in studies on DBS complications or is grouped together with other wound-related complications. As such, there are few patients included in studies reporting on this specific complication and management strategies vary across the literature [1, 4, 5, 12, 13]. For one, Fenoy and Simpson [4] described 3 cases of wound dehiscence successfully managed with wound washouts. However, in another report by Oh et al. [13], only 1 of 8 cases of skin erosions was successfully managed by wound revision without hardware removal.

Explantation of any DBS component requires an additional operation at a later date, often weeks to months later, to replace the part of the system that was removed. We advocate that wound revision with debridement be pursued in cases of wound dehiscence without intraoperative findings of purulent material. Additionally, all cases should be treated with a course of postoperative antibiotics regardless of wound appearance. This strategy may successfully manage the complication and avoid interruption of DBS therapy.

Additionally, patients should be closely monitored for any subsequent complications. In our practice, this involved outpatient office visits every 1–2 weeks to ensure proper wound healing. Once sutures were removed, patients were monitored once monthly until 3 months. Patients were then monitored on an as-needed basis. In those cases that are not successfully managed with wound revision, a second wound revision or partial explantation should be pursued next. In cases of generator dehiscence, reimplantation of the generator beneath the pectoralis muscle or in the abdomen may be considered if the patient is at high risk for dehiscence. If this ultimately fails, total system removal may be necessary. Because it is hard to predict which patients will ultimately require a complete explant, and that most do not require it, we have advocated for an attempt to revise the wounds without explant as the initial step in management.

Wound Revision for Hardware Infections

There was one successful case of intracerebral abscess managed with wound washout and revision. Generally, infections in this study were managed with partial explantation. However, this case deviated from our traditional management. This particular patient had refractory OCD and was desperate to save the DBS. The DBS therapy was considered of such great benefit to the patient that he preferred attempting washout first instead of hardware removal. This was a complex decision made in concert with the patient and family. The patient was monitored in the ICU for 48 h and was in close contact with the surgeon after discharge. The patient was monitored closely with computed-tomography scans and MRIs for 3 months after discharge. Although monitoring would not necessarily prevent clinical decline but would potentially catch a recurrence.

In the series by Fenoy and Simpson [4], in infections of cranial origin, only 25% (2 of 8 infections) were successfully managed with wound washout, and the remaining ultimately required hardware removal. Similarly, Oh et al. [13] reported that all 5 cases who initially underwent hardware-sparing wound washout for infections were unsuccessful and ultimately required removal of the DBS system. The high failure rate of managing infections with wound washout suggests that perhaps this should not be the initial step since at least partial explantation will be required for definitive management. However, in select cases and after careful discussion with the patient, wound washout can be attempted in the presence of hardware infection. We believe that one of the keys to potentially managing these situations is extremely close contact with patients and educating patients and families to immediately reach out if there is even a question of a skin-related issue over or near the hardware.

Partial Explantation for Hardware Infections

The rate of infectious complications cited in the literature varies widely and is challenging to interpret given the multiple definitions of “infection” in these studies. In our study, we define “infection” as those cases where purulent material surrounding any component of the DBS system was identified intraoperatively. The majority of these cases were managed with partial explantation in which the wound was thoroughly washed out, and the involved component was removed. In all cases, patients received antibiotics postoperatively, which were then tailored according to the organism identified from intraoperative wound cultures.

There is no standardized management to date for cases presenting with hardware infections. Several articles have described multiple approaches toward hardware infections, ranging from conservative management with antibiotics to total hardware explantation, with varied success rates [1, 2, 4, 5, 10, 11, 13‒17]. Our management with partial removal was successful in the majority of patients who presented with infection (56%) at the generator in our series. Similarly, Sillay et al. [14] found that partial explantation successfully managed cases presenting with localized infections in 9 out of 14 patients (64%). Abode-Iyamah et al. [11] reported a success rate of 50% in managing generator infections with partial explantation. Fenoy and Simpson [4] reported only one case of infection over the generator, and the patient was successfully managed with generator and extension-wire removal, intravenous antibiotics, and reimplantation 2 months later.

We recommend an initial attempt of saving the intracranial lead in patients found to have a purulent infection involving the extension wire and/or generator at the chest. We advocate removal of the extension wires in these cases at the time of generator removal. This ultimately makes reimplantation easier on the patient by avoiding revision of the intracranial component. The generator and extension wire can be reimplanted after 3–4 months [10].

Intraoperative cultures were sent on all patients with purulence found intraoperatively. Staphylococcus species was the most frequently isolated organism, and there was only one case where the cultures were negative for any organism. Consistent with the literature, other studies have also reported Staphylococcus species to be the most common offending organism [2‒4, 11, 18]. We recommend obtaining intraoperative cultures in all cases of infection in order to dictate appropriate antibiotic management.

Partial Explantation for Wound Dehiscence

Management with partial explantation was pursued in cases with hardware infection with 2 exceptions in our study. There were 2 cases of wound dehiscence without signs of infection that were successfully managed with partial explantation. It was decided not to attempt wound revision in these cases because the skin could not be adequately approximated over the exposed hardware.

Study Limitations

There are several limitations. First, this is a retrospective review at a single institution. Second, although this case series is larger than most other studies reporting similar hardware complications, it is nevertheless a small patient sample. Third, although patients underwent reoperation within 24 h of initial presentation to the emergency department or outpatient follow-up, the exact duration of the complication prior to seeking medical attention was unknown in most cases. This may impact the severity of the complication and response to subsequent therapies. Finally, complications arising following the initial procedure (i.e., Phase II DBS) were grouped with those occurring after routine generator replacement for battery depletion or secondary to trauma. However, it is unlikely that these groups significantly differ from each other [1, 4], and they were not managed differently at our institution.

Wound dehiscence following DBS placement is a common complication that can be successfully managed without removal of the system in majority of cases. In cases of infection with purulence at the generator, removing the involved component(s) but saving the intracranial leads may be considered as the infection resolved with this management in most patients. Reoperation without removal of the entire DBS system is safe, minimizes costs, and can improve quality of life in these patients by preventing or minimizing the withdrawal of DBS treatment. Preservation of the intracranial DBS leads should be initially attempted in cases of wound dehiscence or infection in combination with a course of appropriate antibiotics.

Subjects have given their written informed consent. The study protocol was approved by the Rutgers institutional review board (Pro0220090203).

The authors have no conflicts of interest to declare.

The authors did not receive any funding.

All the authors contributed substantially to this work. E.E.G. was responsible for acquisition of data, analysis of data, interpretation of data, drafting and revising the work, and the final approval of the version to be published. E.H. was responsible for interpretation of data, revising the work, and the final approval of the version to be published. D.L.C. was responsible for revising the work and the final approval of the version to be published. S.F.D. was responsible for the conception of the work, interpretation of data, revising the work critically for important intellectual content, and the final approval of the version to be published.

1.
Atchley
TJ
,
Laskay
NMB
,
Sherrod
BA
,
Rahman
AKMF
,
Walker
HC
,
Guthrie
BL
.
Reoperation for device infection and erosion following deep brain stimulation implantable pulse generator placement
.
J Neurosurg
.
2019
:
1
8
.
2.
Chan
DT
,
Zhu
XL
,
Yeung
JH
,
Mok
VC
,
Wong
E
,
Lau
C
,
.
Complications of deep brain stimulation: a collective review
.
Asian J Surg
.
2009
;
32
(
4
):
258
63
.
3.
Constantoyannis
C
,
Berk
C
,
Honey
CR
,
Mendez
I
,
Brownstone
RM
.
Reducing hardware-related complications of deep brain stimulation
.
Can J Neurol Sci
.
2005
;
32
(
2
):
194
200
.
4.
Fenoy
AJ
,
Simpson
RK
Jr
.
Management of device-related wound complications in deep brain stimulation surgery
.
J Neurosurg
.
2012
;
116
(
6
):
1324
32
.
5.
Jitkritsadakul
O
,
Bhidayasiri
R
,
Kalia
SK
,
Hodaie
M
,
Lozano
AM
,
Fasano
A
.
Systematic review of hardware-related complications of deep brain stimulation: do new indications pose an increased risk
.
Brain Stimul
.
2017
;
10
(
5
):
967
76
.
6.
Weaver
FM
,
Follett
K
,
Stern
M
,
Hur
K
,
Harris
C
,
Marks
WJ
Jr
,
.
Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial
.
JAMA
.
2009
;
301
(
1
):
63
73
.
7.
Williams
A
,
Gill
S
,
Varma
T
,
Jenkinson
C
,
Quinn
N
,
Mitchell
R
,
.
Deep brain stimulation plus best medical therapy versus best medical therapy alone for advanced Parkinson’s disease (PD SURG trial): a randomised, open-label trial
.
Lancet Neurol
.
2010
;
9
(
6
):
581
91
.
8.
Obeso
JA
,
Obeso
JA
,
Olanow
CW
,
Rodriguez-Oroz
MC
,
Krack
P
,
Kumar
R
,
.
Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson’s disease
.
N Engl J Med
.
2001
;
345
(
13
):
956
63
.
9.
Deuschl
G
,
Schade-Brittinger
C
,
Krack
P
,
Volkmann
J
,
Schäfer
H
,
Bötzel
K
,
.
A randomized trial of deep-brain stimulation for Parkinson’s disease
.
N Engl J Med
.
2006
;
355
(
9
):
896
908
.
10.
Helmers
AK
,
Lübbing
I
,
Birkenfeld
F
,
Witt
K
,
Synowitz
M
,
Mehdorn
HM
,
.
Complications of impulse generator exchange surgery for deep brain stimulation: a single-center, retrospective study
.
World Neurosurg
.
2018
;
113
:
e108
e12
.
11.
Abode-Iyamah
KO
,
Chiang
HY
,
Woodroffe
RW
,
Park
B
,
Jareczek
FJ
,
Nagahama
Y
,
.
Deep brain stimulation hardware-related infections: 10-year experience at a single institution
.
J Neurosurg
.
2018
:
1
10
.
12.
Lanotte
M
,
Verna
G
,
Panciani
PP
,
Taveggia
A
,
Zibetti
M
,
Lopiano
L
,
.
Management of skin erosion following deep brain stimulation
.
Neurosurg Rev
.
2009
;
32
(
1
):
111
5
; discussion 114–5.http://dx.doi.org/10.1007/s10143-008-0158-0.
13.
Oh
MY
,
Abosch
A
,
Kim
SH
,
Lang
AE
,
Lozano
AM
.
Long-term hardware-related complications of deep brain stimulation
.
Neurosurgery
.
2002
;
50
(
6
):
1268
74
; discussion 1274–6.http://dx.doi.org/10.1097/00006123-200206000-00017.
14.
Sillay
KA
,
Larson
PS
,
Starr
PA
.
Deep brain stimulator hardware-related infections: incidence and management in a large series
.
Neurosurgery
.
2008
;
62
(
2
):
360
6
; discussion 366–7.http://dx.doi.org/10.1227/01.neu.0000316002.03765.33.
15.
Boviatsis
EJ
,
Stavrinou
LC
,
Themistocleous
M
,
Kouyialis
AT
,
Sakas
DE
.
Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature
.
Acta Neurochir (Wien)
.
2010
;
152
(
12
):
2053
62
.
16.
Temel
Y
,
Ackermans
L
,
Celik
H
,
Spincemaille
GH
,
van der Linden
C
,
Walenkamp
GH
,
.
Management of hardware infections following deep brain stimulation
.
Acta Neurochir (Wien)
.
2004
;
146
(
4
):
355
361
; discussion 61.http://dx.doi.org/10.1007/s00701-004-0219-2.
17.
Baizabal Carvallo
JF
,
Simpson
R
,
Jankovic
J
.
Diagnosis and treatment of complications related to deep brain stimulation hardware
.
Mov Disord
.
2011
;
26
(
8
):
1398
406
.
18.
Gorgulho
A
,
Juillard
C
,
Uslan
DZ
,
Tajik
K
,
Aurasteh
P
,
Behnke
E
,
.
Infection following deep brain stimulator implantation performed in the conventional versus magnetic resonance imaging-equipped operating room
.
J Neurosurg
.
2009
;
110
(
2
):
239
46
.