Imaging Findings of Intracerebral Infection after Deep Brain Stimulation: Pediatric Case Series and Literature Review

Deep brain stimulation (DBS) infection occurs in 3% of adult and 10% of pediatric cases, where the most critical kind is at the intracerebral leads, requiring urgent removal.[1][2][3] Careful confirmation is necessary as explantation elicits symptom reemergence, and reimplantation yields reduced efficacy with an increased reinfection risk.4 Intracerebral DBS infection is underreported, particularly its neuroimaging presentation and occurrences in children.We present the clinical and neuroimaging findings of 4 original pediatric and 24 literature adult cases.Patient 1 (an 11-year-old boy with idiopathic generalized dystonia) received bilateral globus pallidus internus (GPi)-DBS.Six months postoperatively, he developed worsening dystonia and fever, as well as swelling and erythema over the battery, but did not report pain.Incision cultures revealed Staphylococcus aureus.Magnetic resonance imaging (MRI) showed T2/fluidattenuated inversion recovery (FLAIR) hyperintensity in the lentiform nuclei and amygdala without contrast enhancement (CE) (Fig. 1A-F).The leads were explanted and tested positive.Patient 2 (an 11-year-old girl with dyskinetic cerebral palsy secondary to prematurity) received bilateral GPi-DBS.One month later, purulent discharge occurred at the scalp incision, which was tender, and dystonia did not worsen.Cultures revealed S. aureus.MRI indicated CE at the burr hole and T2/FLAIR hyperintensity around the right lead, which was removed and tested positive (Fig. 1G-L).Patient 3 (a 17-year-old boy with dyskinetic cerebral palsy secondary to prematurity) received bilateral GPi-DBS.One year later, the battery and connecting wires were revised due to worsening dystonia and abnormal device impedances.Eight days postoperatively, incisional discharge occurred at the chest without pain.Cultures revealed Serratia, and white blood cell (WBC) count was elevated (13,000).The DBS system was removed, excluding the leads.During this procedure, the lead protrusions were swabbed and tested positive.MRI demonstrated T2/FLAIR hyperintensity of the left-sided lead, and the leads were explanted (Fig. 1M-R; Fig. S1).Patient 4 (a 4-year-old boy with generalized dystonia of presumed genetic etiology) received bilateral GPi-DBS.Three weeks postoperatively, he presented with fever, erythema, and swelling of the chest incision but no pain or worsening dystonia.The battery and connecting wires were removed, swabs indicated S. aureus, and WBC count was elevated (20,800).MRI demonstrated bilateral T2/FLAIR hyperintensity and CE of the leads, which were removed and tested positive (Fig. 1S-X).Overall, our patients were successfully treated with broadspectrum antibiotics.Clinically, 4 children experienced skin changes (eg, erythema), 2 had a fever, and 2 demonstrated worsening dystonia, plausibly due to infection severity, location, involvement of active contacts, and pathogen characteristics (Table S1).On MRI, asymmetric T2/FLAIR hyperintensity was observed in 3 cases and CE in 2, but diffusion restriction was absent (Table S2).A literature review (Table S3) of intracerebral DBS infection, including studies reporting (1) neuroimaging and (2) clinical

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