Stage 2 DBS without the wait: safety of same-day low-amplitude activation in a predominantly unilateral cohort

Postoperative deep brain stimulation (DBS) programming schedules vary across institutions. At some centers, patients may experience an additional post-stage 2 interval without stimulation before the first outpatient programming visit. In the present study, authors evaluated the safety and operational feasibility of a standardized same-day low-amplitude activation protocol on the day of stage 2 DBS surgery compared with a historical delayed-programming pathway at their center.

A retrospective single-center study was conducted using a propensity score-adjusted cohort of consecutive stage 2 DBS procedures performed between 2019 and 2024. Stage 1 denoted intracranial lead implantation, whereas stage 2 signified implantable pulse generator and extension wire insertion. Cases were divided into 2 cohorts, a historical delayed-activation group and an immediate-activation group (same day, conservative current ceilings, fixed contact selection, patient-programmer guardrails). The primary endpoint was the composite 6-month post-stage 2 adverse events rate (surgical, device, or stimulation related).

The study included 561 consecutive procedures (273 delayed, 288 immediate); all had ≥ 6 months of follow-up. In the immediate cohort, the median interval from stage 1 to 2 was 3.0 days (Q1-Q3: 2.5-3.5 days), and the median interval from stage 1 to activation was also 3.0 days (2.5-3.5 days) because of same-day activation. In the delayed cohort, the median interval from stage 1 to 2 was 4.0 days (2-9 days) while the median from stage 1 to activation was 18.0 days (13-29, IQR 16 days). In propensity-adjusted analyses, immediate activation met the noninferiority criterion (upper 95% CI for risk difference < 5%); point estimates favored immediate activation. Unadjusted adverse event rates were 3.8% (11/288) for the immediate cohort versus 20.5% (56/273) for the delayed cohort (risk difference -16.7%, 95% CI -22.0 to -11.4). No device-related deaths occurred. Program stability was greater with immediate activation: at 6 months after the first full programming visit, retention of the settings established at that initial visit was 78.5% in the immediate cohort versus 54.9% in the delayed cohort, and the time to first change favored immediate activation (HR 2.28, 95% CI 1.89-2.73 for delayed vs immediate). Kaplan-Meier curves showed separation persisting to 36 months. In exploratory analyses, bilateral cases had higher short-term speech and altered mental status events, without differences in infection, hemorrhage, erosion, or lead migration.

In a large consecutive, propensity score-adjusted cohort, same-day low-amplitude activation after stage 2 was at least as safe as delayed activation, coinciding with fewer early post-stage 2 adverse events and more durable programming. This protocol shortens the early no-stimulation gap and can be implemented in programs employing unilateral implantation. However, these findings do not establish the safety of immediate full therapeutic activation or comparative motor efficacy. Prospective multicenter evaluations should confirm durability, patient-reported outcomes, and resource use.