title: The impact of brain shift in deep brain stimulation surgery: observation and obviation.
abstract: BACKGROUND
  The impact of brain shift on deep brain stimulation surgery is considerable. In DBS surgery, brain shift is mainly caused by CSF loss. CSF loss can be estimated by post-surgical intracranial air. Different approaches and techniques exist to minimize CSF loss and hence brain shift. The aim of this survey was to investigate the extent and dynamics of CSF loss during DBS surgery, analyze its impact on final electrode position, and describe a simple and inexpensive method of burr hole closure.
  
  
  METHODS
  Sixty-six patients being treated with deep brain stimulation were retrospectively analyzed for this treatise. During surgery, CSF loss was minimized using bone wax as a burr hole closure. Intracranial air volume was calculated based on early post-surgery stereotactic 3D CT and correlated with duration of surgery and electrode deviations derived from post-surgery image fusion.
  
  
  RESULTS
  Median early post-surgery intracranial air was 2.1 cm(3) (range 0-35.7 cm(3), SD 8.53 cm(3)). No correlation was found between duration of surgery and CSF-loss (R = 0.078, p = 0.534), indicating that CSF loss mainly occurs early during surgery. Linear regression analysis revealed no significant correlations regarding volume of intracranial air and electrode displacement in any of the three principal axes. No significant difference regarding electrode deviations between first and second side of surgery were observed.
  
  
  CONCLUSIONS
  CSF loss mainly occurs during the early phase of DBS surgery. CSF loss during a later phase of surgery can be effectively averted by burr hole closure. Postoperative intracranial air volumes up to 35 cm(3) did not result in significant electrode displacement in our series. Comparing our results to studies previously published on this subject, burr hole closure using bone wax is highly effective.
authors.affiliation: Neurochirurgische Klinik, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany. slotty@med.uni-duesseldorf.de
authors.forename: P J
authors.initials: PJ
authors.lastname: Slotty
authors.forename: M A
authors.initials: MA
authors.lastname: Kamp
authors.forename: C
authors.initials: C
authors.lastname: Wille
authors.forename: T M
authors.initials: TM
authors.lastname: Kinfe
authors.forename: H J
authors.initials: HJ
authors.lastname: Steiger
authors.forename: J
authors.initials: J
authors.lastname: Vesper
mesh_terms: D000368:Aged; D002555:Cerebrospinal Fluid; D046690:Deep Brain Stimulation / Q000379:methods*; D004567:Electrodes, Implanted / Q000009:adverse effects; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008875:Middle Aged; D010300:Parkinson Disease / Q000601:surgery; D011184:Postoperative Period; D012189:Retrospective Studies; D013238:Stereotaxic Techniques; D016896:Treatment Outcome