Hemorrhagic complications in deep brain stimulation: analysis of non-surgical risk factors in a cohort of 683 patients

Introduction Deep brain stimulation (DBS) is an established neurosurgical therapy for movement disorders, neuropsychiatric conditions, and drug-resistant epilepsy. Intracranial hemorrhage (ICH) remains among the most severe complications of DBS, with limited data on its risk factors. This study aims to assess the incidence of ICH and evaluate associated non-surgical and selected surgical risk factors in a large, single-center cohort. Methods We retrospectively analyzed 683 patients (1227 DBS electrodes implanted) treated at a single medical center between November 2008 and April 2025. Data on demographics, diagnoses, comorbidities, and surgical techniques were collected and analyzed using both statistical and descriptive methods to identify predictors of ICH. Hemorrhages were classified as symptomatic (transient or permanent) or asymptomatic based on clinical outcome. Results ICH occurred in 34 patients (4.98%), with 40 hemorrhagic events in total (3.26% per lead). Permanent neurological deficits occurred in 6 patients (0.9%). Antithrombotic therapy was the only statistically significant predictor of ICH in both univariate and multivariate models (OR = 4.14, p = 0.002; OR = 3.75, p = 0.006). Microelectrode recording (MER) and number of brain penetrations were associated with symptomatic ICH in univariate analysis but lost significance in multivariate models. No associations were found for sex, age, hypertension, diagnosis, or stereotactic target. Subthalamic nucleus targeting was observed exclusively in patients with permanent deficits. Conclusion DBS remains a safe procedure with low risk of permanent ICH-related morbidity. Antithrombotic therapy is a modifiable risk factor. Continued refinement in perioperative planning and surgical technique is essential to further minimize hemorrhagic risk.