Technique and Accuracy of 3D Fluoroscopy-Confirmed Asleep Deep Brain Stimulator Implantation: A Case Series

Awake deep brain stimulation (DBS) surgery has been associated with extended procedural time and patient discomfort. Asleep DBS, performed under general anesthesia with imaging-based guidance and confirmation, has emerged as an effective alternative. We describe a novel asleep DBS implantation technique using a Leksell stereotactic and the ARTIS Pheno robotic C-ARM with intraoperative 3D (3-dimensional) fluoroscopy (C-ARM 3DF) and assess accuracy and feasibility.

Retrospective review of 9 patients who underwent asleep DBS lead implantation using a Leksell stereotactic frame and intraoperative C-ARM 3DF between January 2024 and February 2025 was performed. Planned lead coordinates in BrainLab software were compared with actual lead positions on postoperative computed tomography, and accuracy was quantified using Cartesian and radial errors.

Among 9 patients (mean age 59.89 ± 19.23 years), the average Cartesian error between planned and actual lead positions was 1.25 ± 0.62 ± mm, and the mean radial error was 0.78 ± 0.31 mm. To assess intraoperative imaging reliability, we compared intraoperative C-ARM 3DF scans with postoperative computed tomography, which demonstrated a mean Cartesian deviation of 1.00 ± 0.80 mm. The average operative time was 105.44 ± 45.92 minutes overall, with bilateral cases averaging 122.57 ± 35.51 minutes and unilateral cases averaging 45.50 ± 7.78 minutes.

Asleep DBS lead implantation using a Leksell stereotactic frame and intraoperative C-ARM 3DF achieves localization accuracy comparable with established awake and asleep methods. This technique is efficient and may be a viable alternative in centers with access to 3D fluoroscopic imaging.