Anti-Coagulation and Deep Brain Stimulation: Never the Twain Shall Meet?

Deep brain stimulation (DBS) for movement disorders is usually performed in older patients who may be prone to vascular co-morbidities such as atrial fibrillation or valvular disease that may require anti-coagulation. This potentially increases the risk of peri-operative intra-cranial haemorrhage and thus anti-coagulation therapy is generally considered a contraindication for DBS implantation. Cessation of anti-coagulants has to be balanced with the risk of thrombosis or ischaemic complications and, to compound issues, there is a paucity of guidelines and consensus on the management of anti-coagulation in patients undergoing DBS. To date, we have performed DBS successfully in 4 patients on lifelong anti-coagulation, having carefully managed their anti-coagulation in the peri-operative period. One patient developed a moderate haematoma around the implantable pulse generator 2 days post-operatively that was treated conservatively. Otherwise no other adverse effects or haemorrhagic complications occurred. We therefore propose that DBS implantation in this group of patients is safe, provided strict observation of protocols and careful management of the anti-coagulation therapy are undertaken. We describe the indications for anti-coagulation and provide a guideline for therapy in such patients according to our experience.