Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Deep Brain Stimulation (DBS) Lead Placement

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with [Parkinson disease / essential tremor / dystonia] planned for [bilateral/unilateral] DBS lead placement targeting [STN / GPi / VIM] [awake with MER / asleep under imaging guidance].

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

CNS Video Library

DBS surgical workflow — preoperative trajectory planning, intraoperative microelectrode recording/microstimulation, and lead-placement assessment

Workflow: planning → MER / microstimulation (ventral STN, dorsal SNr) → lead-placement assessment. Source: Shi et al., Front Neurol 2021;12:683532, Fig 1. CC BY 4.0.

DBS targeting — preoperative MRI plan (targets along the anterior edge of the red nucleus) and postoperative CT–MRI fusion verifying lead location

Preoperative MRI targeting and postoperative CT/MRI-fusion verification of lead position. Source: Shi et al., Front Neurol 2021;12:683532, Fig 2. CC BY 4.0.

Intraoperative microelectrode recording — characteristic STN signal (high background, irregular firing) versus SNr (lower noise, regular high-frequency)

MER signatures distinguishing STN from SNr during trajectory mapping. Source: Shi et al., Front Neurol 2021;12:683532, Fig 4. CC BY 4.0.

Neurosurgical Atlas · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Deep Brain Stimulation Lead Placement — Figure 2. Figure 2.. An axial MRI image showing the misplaced deep brain stimulation (DBS) lead tip on the left side of the brain: (a) It is located posterolaterally to the ideal location (arrow); (b) the… Source: Surgical management of adverse events associated with deep brain stimulation: A single-center experience — SAGE Open Medicine 2020; CC BY-NC.

Deep Brain Stimulation Lead Placement — Figure 3. Figure 3.. X-ray films showing an additional deep brain stimulation (DBS) lead in the globus pallidus interna (GPi) (a) and the replaced dual-channel implantable pulse generator (b). Source: Surgical management of adverse events associated with deep brain stimulation: A single-center experience — SAGE Open Medicine 2020; CC BY-NC.

Deep Brain Stimulation Lead Placement — Figure 4. Figure 4.. A ventrally migrated deep brain stimulation (DBS) lead is shown on the coronal (a) and axial (b, c) CT images and a skull x-ray (d). Two preoperative axial CT images (b, c) show the tips… Source: Surgical management of adverse events associated with deep brain stimulation: A single-center experience — SAGE Open Medicine 2020; CC BY-NC.

Deep Brain Stimulation Lead Placement — Figure 5. Figure 5.. Fractured lead shown on the skull x-ray (a) and intraoperative pictures (b, c). Source: Surgical management of adverse events associated with deep brain stimulation: A single-center experience — SAGE Open Medicine 2020; CC BY-NC.

Deep Brain Stimulation Lead Placement — Figure 5 Figure 5. Source: Surgical management of adverse events associated with deep brain stimulation: A single-center experience — SAGE Open Med. 2020 Mar 19;8:2050312120913458. doi: 10.1177/2050312120913458; CC BY-NC.

Deep Brain Stimulation Lead Placement — Figure 1 Figure 1. (a) Axial CT without contrast enhancement showing hypodense 1.5 cm ovoid lesion in left basal ganglia surrounding deep brain stimulator lead four months after DBS placement. (b) The… Source: Recurrent, Delayed Hemorrhage Associated with Edoxaban after Deep Brain Stimulation Lead Placement — Case Reports in Neurological Medicine 2013; CC BY.

Deep Brain Stimulation Lead Placement — Figure 2 Figure 2. Axial CT without contrast enhancement showing no acute hemorrhage along DBS tract immediately after DBS placement. Source: Recurrent, Delayed Hemorrhage Associated with Edoxaban after Deep Brain Stimulation Lead Placement — Case Reports in Neurological Medicine 2013; CC BY.

Deep Brain Stimulation Lead Placement — Figure 3 Figure 3. Axial CT without contrast enhancement showing 1.9 × 1.5 cm acute hemorrhage in the left cerebral peduncle five months after DBS placement. Source: Recurrent, Delayed Hemorrhage Associated with Edoxaban after Deep Brain Stimulation Lead Placement — Case Reports in Neurological Medicine 2013; CC BY.

Deep Brain Stimulation Lead Placement — Figure 4 Figure 4. Repeat axial head CT without contrast enhancement done 24 hours after initial CT scan showing interval improvement of left cerebral peduncle hemorrhage. Source: Recurrent, Delayed Hemorrhage Associated with Edoxaban after Deep Brain Stimulation Lead Placement — Case Reports in Neurological Medicine 2013; CC BY.

Deep Brain Stimulation Lead Placement — Figure 1: Figure 1:. (a) Unremarkable head computed tomography (CT) performed early on postoperative day (POD) 1. (b) Stat head CT later on POD 1 showing marked left-sided peri-lead edema extending into the… Source: Case report of hyperacute edema and cavitation following deep brain stimulation lead implantation — Surgical Neurology International 2020; CC BY-NC-SA.

History of Present Illness

Imaging Review

MRI (volumetric, target-specific sequences)

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Targets

Technique

Position

Key Surgical Steps

  1. Apply stereotactic frame (local anesthesia), stereotactic CT, merge with planning MRI, calculate coordinates and trajectory
  2. Off dopaminergic meds overnight (PD — for intraop assessment)
  3. Burr hole (typically coronal, ~Kocher’s-type entry), secure lead anchor
  4. Open dura, minimize CSF egress/pneumocephalus (brain shift) — small durotomy, fibrin glue
  5. Microelectrode recording (MER) — advance microelectrode, record characteristic neuronal firing (STN bursting/irregular, GPi, VIM tremor cells, identify borders e.g. SNr below STN)
  6. Map target borders physiologically (awake)
  7. Test stimulation (awake) — assess benefit (tremor/rigidity reduction) and side-effect thresholds (capsular: contractions; medial lemniscus: paresthesia; oculomotor: diplopia)
  8. Implant permanent DBS lead at optimal trajectory/depth, confirm with imaging (CT/fluoro/iMRI)
  9. Secure lead to burr hole anchor
  10. Repeat contralateral side (bilateral)
  11. Intraoperative/postop CT to confirm position and exclude hemorrhage
  12. IPG (pulse generator) placement — same session or staged: subclavicular pocket, tunnel extension to lead

Critical Anatomy & Structures at Risk

  1. Internal capsule (lateral to STN/GPi) — motor side effects
  2. Medial lemniscus, sensory thalamus — paresthesias
  3. Optic tract (below/medial GPi) — visual phenomena
  4. Red nucleus, SNr, oculomotor fibers (STN region)
  5. Vessels/sulci/ventricle along trajectory — hemorrhage (main serious risk)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. Intracranial hemorrhage (~1-2%) — most serious; control BP, limit passes, avoid vessels
  2. Misplacement → poor benefit/side effects (needs revision)
  3. Infection (hardware), lead migration/fracture
  4. Seizure, pneumocephalus/brain shift affecting accuracy
  5. Stimulation side effects (programmable)

Operative Note Template

Preoperative Diagnosis: [Parkinson disease / essential tremor / dystonia], medically refractory

Postoperative Diagnosis: Same

Procedure: [Bilateral] DBS lead placement, target [STN/GPi/VIM], [frame-based, awake with MER / asleep image-guided] [± IPG placement]

Surgeon / Assistant: Anesthesia: [MAC/awake for MER / GA for asleep technique] EBL / Fluids: Minimal Adjuncts: Stereotactic frame [Leksell/CRW] or frameless system, MER, test stimulator, intraoperative CT/fluoro [or iMRI] Implants: DBS lead(s) [± IPG and extensions] Complications: None

Indications: [Age]yo [M/F] with [refractory PD/ET/dystonia] meeting selection criteria (good levodopa response / disabling tremor), cleared by the multidisciplinary committee. Target [STN/GPi/VIM]. Risks (hemorrhage, misplacement, infection) discussed.

Description of Procedure: After consent and time-out, [the stereotactic frame was applied under local anesthesia], a stereotactic CT obtained and merged with the planning MRI, and target/entry coordinates and an avascular trajectory calculated. [Dopaminergic meds were held for intraoperative assessment.] A [coronal] burr hole was made, the lead anchor secured, and the dura opened minimizing CSF loss/pneumocephalus.

Microelectrode recording was performed, characteristic firing identified, and the target borders mapped. Awake test stimulation confirmed clinical benefit ([tremor/rigidity reduction]) and acceptable side-effect thresholds (capsular/sensory/oculomotor). The permanent DBS lead was implanted at the optimal trajectory/depth and secured, with position confirmed on [CT/fluoro/iMRI]. [The contralateral side was performed identically.] Intraoperative/postoperative imaging excluded hemorrhage. [The IPG was placed in a subclavicular pocket and tunneled.]

The patient was transferred in stable condition; programming was planned at ~2–4 weeks.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Deep Brain Stimulation (DBS) Lead Placement:

Common Pimp Questions

Use these to pressure-test preparation for Deep Brain Stimulation (DBS) Lead Placement:

  1. What is the symptom target and what finding proves the correct neural structure is being treated?
  2. What imaging, tractography, MER, stimulation, or mapping information changes the trajectory?
  3. What medication adjustments or anesthesia constraints matter on the day of surgery?
  4. What complication would be subtle but important to detect in recovery?
  5. What postop programming, imaging, seizure, swallow, or cranial-nerve plan is needed?

Attending Preference Variables

Items that commonly vary by surgeon or institution: