title: Delayed clinical improvement after deep brain stimulation-related subdural hematoma. Report of 4 cases.
abstract: OBJECTIVE
  The purpose of this paper is to present 4 cases that illustrate the management and outcome of subdural hematoma (SDH) following deep brain stimulation (DBS) lead implantation.
  
  
  METHODS
  The authors identified 4 cases of SDH following DBS lead implantation from a pool of 500 consecutive lead implantations (incidence 0.08%) performed at the University of Florida. Cases were characterized by chart review, serial Unified Parkinson's Disease Rating Scale evaluations, and changes on serial postoperative imaging studies.
  
  
  RESULTS
  Two of the 4 patients with DBS-related SDH were clinically symptomatic. In the other 2 cases the SDH was incidentally discovered on routine postoperative lead localization imaging studies. None of the patients required craniotomy for evacuation of the SDH in the acute phase. Three of the 4 cases were managed with bur hole drainage in the chronic phase, and one was successfully managed nonoperatively. In all 4 cases, thresholds for stimulationinduced side effects were lower during initial postoperative programming than during intraoperative macrostimulation. Expected clinical improvement from DBS was achieved without lead revision in all 4 cases, but only after a significant delay.
  
  
  CONCLUSIONS
  Subdural hematoma is a rare and potentially avoidable complication of DBS that does not typically mandate acute hematoma evacuation or hardware revision and does not preclude an excellent outcome from DBS therapy. The clinical picture and apparent lead position tend to improve with time, and it may be wise to delay repositioning of an ineffective DBS lead following a hemorrhage until the DBS lead and surrounding brain tissue have settled into their final position and the insulted brain has had sufficient time to recover.
authors.affiliation: Department of Neurology, University of Florida Movement Disorders Center, Gainesville, USA.
authors.forename: Genko
authors.initials: G
authors.lastname: Oyama
authors.forename: Michael S
authors.initials: MS
authors.lastname: Okun
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Zesiewicz
authors.forename: Tiffany
authors.initials: T
authors.lastname: Tamse
authors.forename: Janet
authors.initials: J
authors.lastname: Romrell
authors.forename: Pamela
authors.initials: P
authors.lastname: Zeilman
authors.forename: Kelly D
authors.initials: KD
authors.lastname: Foote
mesh_terms: D000368:Aged; D001921:Brain / Q000601:surgery*; D016208:Databases, Factual; D046690:Deep Brain Stimulation / Q000009:adverse effects*; D004322:Drainage; D004567:Electrodes, Implanted / Q000009:adverse effects*; D005500:Follow-Up Studies; D006408:Hematoma, Subdural / Q000209:etiology* / Q000601:surgery / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D010300:Parkinson Disease / Q000628:therapy; D020127:Recovery of Function