some patients may experience excessive tongue protrusion , squinting , muddled speech , or uncontrollable contraction of the platysma muscle . implantationof deep brain stimulators ( dbs ) has been increasingly used forthe treatment of parkinson 's disease . the procedure includesmultiple steps : application of a stereotactic frame over thehead under radiology imaging , implantation of the stimulatorinto the brain through a burr hole , guided by neurophysiologicaltesting , and subcutaneous tunneling of the dbs wires . the demands of the procedure were challenging for anesthesiologist . the patient has to be comfortable , responsive over an extended period of time . we present a case of meige 's syndrome in which successful palladial dbs implantation was done . a 60-kg , 54-year - old man presented with history of involuntary movement of perioral region , twitching of neck muscles and difficulty in swallowing since 3 years . patient gives past history of some psychiatric illness for which he took treatment which was stopped 10 years back . all investigations were within normal limits . on examination patient was conscious , cooperative , comfortable , and well oriented . the patient and his relatives were explained about the nature of the procedure and written informed consent was taken . the stereotacticrigid frame was applied to the patient 's head under local infiltrationwith 0.25% bupivacaine with epinephrine 1:200,000 in the preoperativeholding area [ figure 1 ] . patient was taken up for computed tomography(ct ) localization for which no sedation was given to the patient . on arrival in the operating room , standardanesthesia monitoring was appliedand supplemental oxygen was provided using hudson mask . venous access was taken on left hand and intravenous ( iv ) infusion was started slowly . the rigid head - framehalo was anchored to the operating table in a position optimalfor surgical approach , as well as for patient comfort . dexmedetomidine was given initially as a bolus of 1 mcg / kg ( 60 mcg ) over 10 min , which was followed by continuous iv infusion @ 0.5 mcg / kg / h . the vitals were observed continuously and the dose adjusted , between 0.2 and 0.7 mcg / kg / h , after assessing the sedation level every 30 min . the sedation end - point was a comfortable and tranquil patient who responded to oral commands . burr - hole was made after local infiltration with bupivacaine ( 0.25% ) and lignocaine ( 1% ) . thearea of interest , in the globus pallidus , was localized with microelectrode recordings ( mer ) throughthe burr - hole and micropotentials of movement - relatedneurons were recorded . dbs electrodes were implanted and after macrostimulation testing of clinical changes in intensity of perioral movement and twitching of neck , to verify correct placement . during mer localization and the clinical testing of implanted dbs electrode lead , after the completion of dbs electrodelead implantation and testing , the stereotactic frame was removed . dexmedetomidine infusion was continued and the patient was given general anesthesia forsubcutaneous tunneling of the extension lead and implantationof the pulse generator subcutaneously into the chest wall . generalanesthesia was induced with propofol 150 mg and endotracheal intubation was facilitated with muscle relaxant vecuronium 6 mg . anesthesia was maintained with isofluraneand fentanyl 100 mcg . at the end of the procedure , patient with stereotactic frame the procedure lasted for 12 h. postoperatively patient was conscious , oriented , and stable . the implanted pulse generator battery was started 2 days later and within a week the patient showed dramatic improvement in his symptoms . meige 's syndrome is a rare form of oral - facial dystonia and unfortunately is not treatable . implantation of pallidal dbs for meige 's syndrome is practiced in refractory cases and the results are effective . an ideal anesthetic regimen for dbs implantationshould consider patient comfort , hemodynamic stability , andrespiratory sufficiency . in addition , the anesthetic goals indbs implantation should include keeping the patient awake , cooperative , comfortable , and preserving the movement disorder for mapping purposes . unfortunately , commonly used sedative drugs such as propofol and midazolam ameliorate tremor(or rigidity ) , involuntary movement , and interfere with brain mapping and testing ofthe implanted dbs electrode lead . moreover , these medicationseasily impair the level of consciousness and may cause respiratorydepression leading to disastrous complications due to difficultywith access to the airway , which is constrained by the bulkymetal frame and the head fixed in a flexed position . the pharmacologic profile of the -2 agonist dexmedetomidine makes it appealing to use for dbs implantations as it provides sedation , maintains hemodynamic stability ( controls hypertension ) , andcauses minimal respiratory depression , even in large doses . we kept the continuous infusion of dexmedetomidine between range of 0.20.7 mcg / kg / h throughout the procedure . during the making of the burr - hole , the infusion rate was kept at 0.7 mcg / kg / h to deepen the sedation . patient tolerated the procedure well and did not need any analgesia except local anesthetic infiltration . during mer and clinical testing we lightened the sedation by reducing the infusion rate to 0.2 mcg / kg / h . the patient stayed comfortable and sedated and the surgeons were satisfied with the patient 's cooperation during mapping . dexmedetomidine did not ameliorate clinical signs of involuntary movements , as has been demonstrated earlier in a case series of dbs implantation in parkinson 's disease . arterial hypertensionis a major risk factor for intracerebral hemorrhage in dbs implantations and thus maintenance of blood pressure during procedure is important . the systolic blood pressure was less than 150 mmhg throughout the procedure demonstrating the hemodynamic stabilizing property of dexmedetomidine . heart rate was maintained between 50 and 60/min and no hemodynamic instability was noted . during the major part of the procedure the role of dexmedetomidine as an anesthetic adjuvant is established.[79 ] we conclude that it is an effective agent in managing cases for dbs implantation .
meige 's syndrome is rare form of orofacial dystonia . 
 there is unfortunately no cure , but occasionally patients may improve with time . 
 we present the successful management of a palladial deep brain stimulator ( dbs ) implantation for meige 's syndrome . 
 dexmedetomidine infusion was used for sedation . 
 the procedure lasted for around 12 h and the patient was comfortable , responsive , and cooperative over the extended period of time . 
 the surgeons were comfortable with electrophysiologic brain mapping and clinical testing . 
 dbs were implanted , through a burr hole , into the globus pallidus neurophysiological testing under guidance . 
 the pulse generator battery was subcutaneously implanted into the chest wall under general anesthesia . 
 the implanted pulse generator battery was started 2 days later and the patient showed dramatic improvement in his symptoms .