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= Idiopathic delayed-onset-edema =

Idiopathic delayed-onset edema

The idiopathic delayed-onset edema is a rare complication related to DBS (deep brain stimulation) which is produced when edema appears surrounding the area where electrodes were implanted. Deep brain stimulation is a safe procedure that rarely produces complications. DBS is used to treat some psychiatric complications, such as depression resistant to medication, obsessive-compulsive disorder, and neurological conditions as Parkinson’s disease; and it has shown a high number of successes.

Definition

Idiopathic delayed-onset edema (IDE) was defined as edema related with the deep brain stimulation. Specifically, the area surrounding the electrodes starts presenting edema, occurring after seventy-two hours past the surgery when there is no other demonstrable cause such as vascular events, brain traumatic injuries, infection, ischemia, and brain hemorrhages.

Symptoms

Symptoms could appear in the last seventy-two hours or even within three months after surgery was performed. Patients with idiopathic delayed-onset edema may present a confusional state, which is the most common manifestation along with headaches and comitial crisis, which are less common than the confusional state But in a minor number of patients, it can also present dysarthria, aphasia, deterioration of stimulation effect, apathy, depression, seizures, hemiparesis, diminished level of consciousness, diplopia, urine incontinence, and agitation. On rare occasions, patients can be totally asymptomatic, which is identified by neuroimaging, which medical doctors do in the follow-up. The neuroimage shows edema surrounding the area of implantation of the electrode which we can see as radiopaque in the neuroimaging.

Etiology

Just as the name said, the etiology of idiopathic delayed-onset edema is idiopathic it means that the causes and predisposing factors which made this complication occur are unknown so far, anyways there are some possible explanations about why this happen mostly related to allergies or local reaction against the electrode’s material, but this is not confirmed yet.

Management or treatment

Management can vary according to patient requirements. In clinical practice, antibiotics and steroids can be used; and on some occasions can be treated conservatively, according to the patient situation it means whether it is stable, symptomatic, or not, medical doctors can use, just antibiotics, just steroids, or both in combination, even though in some guides to treat delayed idiopathic onset edema do not recommend using any medication as some cases are solved without treatment.

In some case studies, they have used antibiotics such as ceftazidime, ceftriaxone, gentamicin, levofloxacin, linezolid, meropenem, rifampicin, sulfamethoxazole, trimethoprim, and vancomycin, even though those are not recommended by the guidelines as etiology is unknown yet.

Steroids that can be used are dexamethasone or prednisolone.

Anyhow, the delayed onset edema is a self-limiting condition, which means it can heal without treatment; and because of this, even when antibiotics and steroids could be used, they are not the first-line treatment recommendation, is recommended a follow-up with neuroimaging regularly

Prognosis

Patients may present total recovery from symptoms around a week after starting treatment, or three weeks, but neuroimaging can last from a week to even up to two months for totally showing resolution of radiological signs of edema. However, radiological signs can be present for more time than symptoms, patients can be asymptomatic and still present radiological sings in the neuroimaging. Some research shows that recovery can be faster or shorter according to the size of the edema in the brain, and how many areas have been affected in the brain. Totally recovery in patients can vary, it means, no symptoms or neuroimaging symptoms at all, it can take even more than a year in some patients for present full recovery from IDE, in those patients the prognosis is not that bad, the early diagnosis help personal health to avoid removal electrodes or unnecessary procedures which may be expensive, aggressive, and even dangerous in some cases., for example, surgeries performed in traumatic brain injuries, hemorrhages or tumor, can have complications such as cerebral infection, coma, brain swelling, headaches, or the worst cases death.

Differential diagnosis

Since symptoms in IDE are a bit unspecific, and considering this fact the clinicians have to be critical while are suspecting this diagnosis, clinicians should discard other possibilities such as, Intracerebral hemorrhage, which is also a rare complication related to deep brain stimulation, and the treatment, in this case, tend to be more aggressive, for example in a hemorrhage with large hematomas might be necessary use brain surgery for bleed evacuation, also in case of brain infection symptoms can be similar, but something important that we have to keep in mind is that complications similar to ICH (intracranial hemorrhage), infections and ischemia, cause permanent symptoms and would cause permanent brain damage if are not treated on time. In the case of cerebral brain infection clinical symptoms may be similar but we can easily distinguish by analyzing fluids, blood, spinal fluid, etc. in labs report in case of infection might appear elevated C reactive protein, white blood cells, and positive bacterial cultures, A delayed onset is not expected in cases of ICH or ischemia, which usually occur peri-operatively (before seventy-two hours after surgery). But it has occasionally been reported following venous infarctions (up to four days after surgery) and infectious cerebritis. Imaging can help distinguish between these conditions. ICH and arterial infarctions are usually clearly recognizable in brain imaging infarctions are localized at the subcortical level while idiopathic delayed onset edema will be in surrounding the area where the electrodes where collocated, usually associated with edema and hemorrhage Infectious cerebritis presents as a hypodense lesion, sometimes accompanied by abscess formation with ring contrast enhancement.

Possible pathogenesis

There is no confirmed pathogenesis for idiopathic onset delayed edema, nevertheless, there are beliefs that some of the following mechanisms could be possibly related to IDE.

·         A possible mechanism causing edema is an inappropriate immune reaction to the leads, such as an allergic reaction or a foreign body reaction (FBR) this is an acute cytokine response against a foreign body, this has happened with other procedures such as stents or aneurysms wrapping materials

·         Hypersensitivity to silicone components

·         Possible allergic skin reactions to DBS components (Even though before the surgery test are made through the laboratory to confirm biocompatibility with the components) Moreover, similar delayed reactions (not otherwise explained) have also been described after other intracranial implants, such as catheters for intracranial pressure monitoring, Ommaya reservoirs or [https://www.healthline.com/health/ventriculoperitoneal-shunt#:~:text=A%20ventriculoperitoneal%20(VP)%20shunt%20is,collects%20in%20the%20brain's%20ventricles. ventricle-peritoneal shunts].

·         Electrodes occluded the microvessels and caused this edema

·         Breakdown of the blood-brain barrier (BBB) due to micro-trauma from MER and lead electrode placement

These possible pathogenesis are not demonstrated yet, otherwise, some patients have presented eosinophils cells surrounding the area, which are the cells related to allergy reaction, inflammatory reaction, and hypersensitivity systemic response.

It is important to know the differences between the idiopathic delayed edema and other pathologies in the brain that may cause similar symptomatology, as IDE is a self-limiting condition, and pathologies, such as, brain tumors, traumatic brain injuries, intracranial hemorrhages, etc. usually required emergency intervention that could be avoided by knowing what is really happening.

Knowing that deep brain stimulation is a safe procedure, but even the simplest procedures can have complications, follow-up and careful observation are highly recommended after every surgery does no matter how minor it is.