Authors: Huang D et al.
Anesthesiology 144(4):1021–1024, April 2026
Summary:
This prospective exploratory study evaluates a novel general anesthesia strategy using Remifentanil and Esketamine for deep-brain stimulation (DBS) surgery in patients with Parkinson disease. Traditionally, DBS electrode placement is performed under awake or lightly sedated conditions to preserve microelectrode recording signals, but this approach can be uncomfortable and challenging for both patients and surgeons.
The authors tested whether a non-GABAergic general anesthesia technique could preserve neurophysiologic signals while improving patient comfort. In 20 patients, continuous infusions of remifentanil and esketamine were used during the critical microelectrode recording phase, avoiding agents like Propofol that suppress cortical activity.
The results were promising. High-quality microelectrode recordings were achieved in 90% of cases, allowing accurate identification of the subthalamic nucleus. Surgical success was high, with correct electrode placement confirmed in all patients. Importantly, patient experience improved—90% reported satisfaction, and there was minimal cognitive decline and no intraoperative awareness.
The physiologic rationale is that this combination avoids widespread cortical suppression. Remifentanil provides analgesia, while esketamine maintains neuronal activity patterns necessary for mapping. Additionally, the study identified gamma oscillation patterns as a potential intraoperative marker for targeting.
Despite its strengths, the study is limited by its small size, single-arm design, and short follow-up. However, it challenges the long-standing assumption that general anesthesia is incompatible with effective DBS mapping.
Overall, this approach may offer a practical alternative to awake DBS surgery, balancing signal quality with patient comfort.
Key Points:
- Remifentanil–esketamine anesthesia preserves microelectrode recording quality
- Avoids GABAergic suppression seen with propofol-based techniques
- High surgical success with accurate electrode placement
- Improved patient comfort and satisfaction compared to awake techniques
- Gamma oscillations may serve as a targeting marker
- Limited by small sample size and lack of comparison group
What You Should Know:
This could be a meaningful shift in DBS anesthesia. If you can maintain signal quality under general anesthesia, you eliminate one of the biggest burdens of awake surgery. The key is avoiding GABA-heavy agents and preserving brain activity.
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