Closed-Loop Deep Brain Stimulation: A Primer for the Perioperative Physician

Abstract Deep brain stimulation (DBS) is an established neuromodulation therapy for a range of neurological and psychiatric disorders, including Parkinson disease, dystonia, essential tremor, epilepsy, and obsessive-compulsive disorder. Conventional DBS systems operate in an open-loop manner, delivering continuous stimulation with fixed parameters that require periodic manual reprogramming. This approach does not account for dynamic fluctuations in disease state and may result in suboptimal symptom control. Advances in neuro-engineering have led to the development of closed-loop DBS systems, which automatically adjust stimulation parameters in real time based on patient-specific neural and behavioral biomarkers. Closed-loop DBS integrates sensing, control, and stimulation components to enable adaptive neuromodulation, with the aid of artificial intelligence and biomarkers. As the clinical adoption of closed-loop DBS expands, perioperative physicians are more likely to encounter patients with these systems. An understanding of their mechanisms, advantages over open loop DBS, and unique perioperative considerations is essential. This primer provides an overview of the evolution, principles, and perioperative implications of closed-loop DBS to support safe and effective clinical care.