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Electronic Letters to:

Case Reports:
A. Glossop and P. Dobbs
Coronary artery vasospasm during awake deep brain stimulation surgery
Br. J. Anaesth. 2008; 0: aen149v1-3 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read E-letter] Coronary vasospasm during anaesthesia for DBS insertion
Dhuleep S Wijayatilake, Hu Low, Lashmi Venkatraghavan   (27 August 2008)

Coronary vasospasm during anaesthesia for DBS insertion 27 August 2008
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Dhuleep S Wijayatilake,
Consultant Neuroanaesthesia ,
Hu Low, Lashmi Venkatraghavan

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Re: Coronary vasospasm during anaesthesia for DBS insertion

Editor- We read with great interest the article by Glossop and Dobbs(1) relating to two patients experiencing chest pain, tachycardia, hypertension and oxygen desaturation during the insertion of brain electrodes for deep brain stimulation (DBS) under local anaesthesia. These episodes were associated with ST-segment changes and elevation of troponin levels. The authors postulate that the symptoms resulted from coronary artery vasospasm secondary to DBS surgery. We have had a similar case in one of our institutions within the last 2 years also with a negative angiogram and agree the cause as in the cases reported was most likely coronary vasospasm.

From a neurosurgical perspective we propose a mechanism that might explain the cardiovascular signs for one of the cases. The hypothalamus is a complex region with many different nuclei. Animal studies have shown that stimulation in Paraventricular region can cause hypertension (2, 3) or hypotension (4). It is possible that current spread to the hypothalamus during thalamic surgery in case 2, causing the hypertension and tachycardia. But this would not be expected during Pallidal DBS surgery (case 1) as the macrostimulating probe should not enter the hypothalamus, and in this case the mechanism remains unclear.

DBS is now a well established procedure however the potential anaesthetic complication rate is high (5). We wholeheartedly concur the presence of an experienced anaesthetist throughout the case using full patient monitoring is mandatory to ensure prompt recognition and treatment of complications to ensure patient safety.

However we cannot agree with the authors suggestion to premedicate these patients with beta blockers and nitrates. Treatment guidelines for coronary vasospasm recommend treatment with calcium channel blockers and nitrates not beta blockers. Furthurmore beta blockers have been shown to reduce spiking activity in micro electrode recording (6) used by most centres during surgery to confirm accurate electrode placement. Thus use of beta blockers may make these responses impossible to interpret during surgery making optimal electrode placement impossible. The effects of calcium blockers and nitrates on micro electrode recording is unknown and needs further investigation before recommendations on use as routine premedication in patients at risk of coronary vasospasm can be made.

1. Glossop A. Dobbs P. Coronary artery vasospasm during awake deep brain stimulation surgery. BJA 2008; 101(2):222-4.

2. Takeda L and Buñag RD. Sympathetic Hyperactivity during Hypothalamic Stimulation in Spontaneously Hypertensive Rats. J Clin Invest. 1978; 62(3): 642–648.

3. Mack SO, Wu M, Kc P, Haxhiu M. Stimulation of the hypothalamic paraventricular nucleus modulates cardiorespiratory responses via oxytocinergic innervation of neurons in pre-Bötzinger complex . Journal of applied physiology. 2007; 102(1):189-199.

4. Kannan, H, Niijima A and Yamashita H. Effects of stimulation of the hypothalamic paraventricular nucleus on blood pressure and renal sympathetic nerve activity. Brain-Res-Bull. 1988; 20(6): 779-83.

5. Venkatraghaven L et al. Anesthesia for Functional Neurosurgery: Review of Complications. Journal of Neurosurgical Anesthesiology. 2006; 18(1):64-67

6. Coenen VA. et al. Noradrenergic modulation of subthalamic nucleus activity in human: metoprolol reduces spiking activity in microelectrode recordings during deep brain stimulation surgery for Parkinson's disease. Acta Neurochirurgica 2008; 150(8):757-762.

Conflict of Interest:

None declared