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Reinacher PC, Várkuti B, Krüger MT, Piroth T, Egger K, Roelz R, Coenen VA. Automatic Segmentation of the Subthalamic Nucleus: A Viable Option to Support Planning and Visualization of Patient-Specific Targeting in Deep Brain Stimulation. Oper Neurosurg (Hagerstown) 2019; 17:497-502. [PMID: 30860266 DOI: 10.1093/ons/opz015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 01/31/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Automatic segmentation is gaining relevancy in image-based targeting of neural structures. OBJECTIVE To evaluate its feasibility, we retrospectively analyzed the concordance of magnetic resonance imaging (MRI)-based automatic segmentation of the subthalamic nucleus (STN) and intraoperative microelectrode recordings (MERs). METHODS Electrodes (n = 60) for deep brain stimulation were implanted in the STN of patients (n = 30; median age 57 yr) with Parkinson disease (n = 29) or rapid-onset dystonia parkinsonism (n = 1). Elements (Brainlab, Munich, Germany) were used to segment the STN, using 2 volumetric T1 (±contrast) and volumetric T2 images as input. The stereotactic computed tomography was coregistered with the imaging, and the original stereotactic coordinates were imported. MERs (0.5-1 mm steps) along the anterior, central, and lateral trajectories were used to determine differences between the image-segmented STN boundary and MER-based STN entry and exit. RESULTS Of 175 trajectories, 105 penetrated or touched (≤0.7 mm) the STN. The overall median deviation between the segmented STN boundary and electrophysiological recordings was 1.1 mm for MER-based STN entry and 2.0 mm for STN exit. Regarding the entry point of the STN, there was no statistically significant difference between MRI-based automatic segmentation and the electrophysiological trajectories analyzed with intraoperative MER. The exit point was significantly different between both methods in the central and lateral trajectories. CONCLUSION MRI-based automatic segmentation of the STN is a viable, patient-specific targeting approach that can be used alongside traditional targeting methods in deep brain stimulation to support preoperative planning and visualization of target structures and aid postoperative optimization of programming.
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Affiliation(s)
- Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bálint Várkuti
- Department of Functional and Stereotactic Neurosurgery, Brainlab AG, Olof Palme Straße 9, Munich, Germany
| | - Marie T Krüger
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Piroth
- Department of Neurology, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Verhagen R, Schuurman PR, van den Munckhof P, Contarino MF, de Bie RMA, Bour LJ. Comparative study of microelectrode recording-based STN location and MRI-based STN location in low to ultra-high field (7.0 T) T2-weighted MRI images. J Neural Eng 2016; 13:066009. [DOI: 10.1088/1741-2560/13/6/066009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Heo YJ, Kim SJ, Kim HS, Choi CG, Jung SC, Lee JK, Lee CS, Chung SJ, Cho SH, Lee GR. Three-dimensional fluid-attenuated inversion recovery sequence for visualisation of subthalamic nucleus for deep brain stimulation in Parkinson's disease. Neuroradiology 2015; 57:929-35. [PMID: 26156865 DOI: 10.1007/s00234-015-1555-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/24/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an accepted treatment for advanced Parkinson's disease (PD). However, targeting the STN is difficult due to its relatively small size and variable location. The purpose of this study was to assess which of the following sequences obtained with the 3.0 T MR system can accurately delineate the STN: coronal 3D fluid-attenuated inversion recovery (FLAIR), 2D T2*-weighted fast-field echo (T2*-FFE) and 2D T2-weighted turbo spin-echo (TSE) sequences. METHODS We included 20 consecutive patients with PD who underwent 3.0 T MR for DBS targeting. 3D FLAIR, 2D T2*-FFE and T2-TSE images were obtained for all study patients. Image quality and demarcation of the STN were analysed using 4-point scales, and contrast ratio (CR) of the STN and normal white matter was calculated. The Friedman test was used to compare the three sequences. RESULTS In qualitative analysis, the 2D T2*-FFE image showed more artefacts than 3D FLAIR or 2D T2-TSE, but the difference did not reach statistical significance. 3D FLAIR images showed significantly superior demarcation of the STN compared with 2D T2*-FFE and T2-TSE images (P < 0.001, respectively). The CR of 3D FLAIR was significantly higher than that of 2D T2*-FFE or T2-TSE images in multiple comparison correction (P < 0.001), but there was no significant difference in the CR between 2D T2*-FFE and T2-TSE images. CONCLUSION Coronal 3D FLAIR images showed the most accurate demarcation of the STN for DBS targeting among coronal 3D FLAIR, 2D T2*-FFE and T2-TSE images.
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Affiliation(s)
- Young Jin Heo
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
- Department of Radiology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Sang Joon Kim
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea.
| | - Ho Sung Kim
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Choong Gon Choi
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Seung Chai Jung
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Jung Kyo Lee
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chong Sik Lee
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sun J Chung
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - So Hyun Cho
- Department of Radiology, Sebarun Hospital, Busan, Korea
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Wagle Shukla A, Okun MS. Surgical treatment of Parkinson's disease: patients, targets, devices, and approaches. Neurotherapeutics 2014; 11:47-59. [PMID: 24198187 PMCID: PMC3899492 DOI: 10.1007/s13311-013-0235-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Surgical treatment for Parkinson's disease (PD) has evolved from ablative procedures, within a variety of brain regions, to implantation of electrodes into specific targets of the basal ganglia. Electrode implantation surgery, referred to as deep brain stimulation (DBS), is preferred to ablative procedures by many experts owing to its reversibility, programmability, and the ability to be safely performed bilaterally. Several randomized clinical studies have demonstrated the effectiveness of DBS surgery for control of PD symptoms. Many brain targets, including the subthalamic nucleus and the globus pallidus internus, have emerged as potentially effective, with each target being closely associated with important pros and cons. Selection of appropriate PD candidates through a methodical interdisciplinary screening is considered a prerequisite for a successful surgical outcome. Despite recent growth in DBS knowledge, there is currently no consensus on the ideal surgical technique, the best surgical approach, and the most appropriate surgical target. DBS is now targeted towards treating specific PD-related symptoms in a given individual, and not simply addressing the disease with one pre-defined approach. In this review we will discuss the historical aspects of surgical treatments, the selection of an appropriate DBS candidate, the current surgical techniques, and recently introduced DBS-related technologies. We will address important pre- and postoperative issues related to DBS. We will also discuss the lessons learned from the randomized clinical studies for DBS and the shifting paradigm to tailor to a more patient-centered and symptom-specific approach.
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Affiliation(s)
- Aparna Wagle Shukla
- Center for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, 3450 Hull Road, Gainesville, FL, 32607, USA,
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Discrepancies between the MRI- and the electrophysiologically defined subthalamic nucleus. Acta Neurochir (Wien) 2011; 153:2307-18. [PMID: 21744142 DOI: 10.1007/s00701-011-1081-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 06/22/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of our study was to evaluate discrepancies between the electrophysiologically and MRI-defined subthalamic nucleus (STN) in order to contribute to the ongoing debate of whether or not microelectrode recording (MER) provides additional information to image-guided targeting in deep brain stimulation. METHODS Forty-four STNs in 22 patients with Parkinson's disease were investigated. The three-dimensional MRI-defined STN was derived from segmentations of axial and coronal T2-weighted images. The electrophysiological STNs were generated from intraoperative MERs in 1,487 locations. The stereotactical coordinates of positive and negative STN recordings were re-imported to the planning software, where a three-dimensional reconstruction of the electrophysiological STN was performed and fused to the MRI data set. The estimated borders of the MRI- and MER-STN were compared. For statistical analysis Student's t, Mann-Whitney rank sum and Fisher's exact tests were used. RESULTS MER-STN volumes, which were found outside the MRI-STN, ranged from 0 mm(3) to 87 mm(3) (mean: 45 mm(3)). A mean of 44% of the MER-STN volumes exceeded the MRI-STN (maximum: 85.1%; minimum: 15.1 %); 53.4% (n = 793) of the microelectrode recordings were concordant and 46.6% (n = 694) discordant with the MRI-defined anatomical STN. Regarding the dorsal borders, we found discrepancies between the MER- and MRI-STN of 0.27 mm (= mean; SD: 0.51 mm) on the first operated side and 1.51 mm (SD: 1.5 mm) on the second (p = 0.010, t-test). CONCLUSIONS MER provides additional information to high-resolution anatomical MR images and may help to detect the amount and direction of brain shift.
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Brunenberg EJL, Platel B, Hofman PAM, Ter Haar Romeny BM, Visser-Vandewalle V. Magnetic resonance imaging techniques for visualization of the subthalamic nucleus. J Neurosurg 2011; 115:971-84. [PMID: 21800960 DOI: 10.3171/2011.6.jns101571] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The authors reviewed 70 publications on MR imaging-based targeting techniques for identifying the subthalamic nucleus (STN) for deep brain stimulation in patients with Parkinson disease. Of these 70 publications, 33 presented quantitatively validated results. There is still no consensus on which targeting technique to use for surgery planning; methods vary greatly between centers. Some groups apply indirect methods involving anatomical landmarks, or atlases incorporating anatomical or functional data. Others perform direct visualization on MR imaging, using T2-weighted spin echo or inversion recovery protocols. The combined studies do not offer a straightforward conclusion on the best targeting protocol. Indirect methods are not patient specific, leading to varying results between cases. On the other hand, direct targeting on MR imaging suffers from lack of contrast within the subthalamic region, resulting in a poor delineation of the STN. These deficiencies result in a need for intraoperative adaptation of the original target based on test stimulation with or without microelectrode recording. It is expected that future advances in MR imaging technology will lead to improvements in direct targeting. The use of new MR imaging modalities such as diffusion MR imaging might even lead to the specific identification of the different functional parts of the STN, such as the dorsolateral sensorimotor part, the target for deep brain stimulation.
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Affiliation(s)
- Ellen J L Brunenberg
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.
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Vitek JL, Lyons KE, Bakay R, Benabid AL, Deuschl G, Hallett M, Kurlan R, Pancrazio JJ, Rezai A, Walter BL, Lang AE. Standard guidelines for publication of deep brain stimulation studies in Parkinson's disease (Guide4DBS-PD). Mov Disord 2010; 25:1530-7. [PMID: 20544809 DOI: 10.1002/mds.23151] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
While the use of deep brain stimulation (DBS) for the treatment of neurological disorders has risen substantially over the last decade, it is often difficult to compare the results from different studies due to the lack of consistent reporting of key study parameters. We present guidelines to standardize the reporting of clinical studies of DBS for Parkinson's disease (PD). These guidelines provide a minimal set of required data elements to facilitate the interpretation and comparison of results across published clinical studies. The guidelines, summarized in the format of a checklist, may also have utility in the planning of clinical studies of DBS for PD as well as other neurological and psychiatric disorders.
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Affiliation(s)
- Jerrold L Vitek
- Neuromodulation Research Center, Department Neurology and Neuroscience, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Shin M, Penholate MF, Lefaucheur JP, Gurruchaga JM, Brugieres P, Nguyen JP. Assessing Accuracy of the Magnetic Resonance Imaging-Computed Tomography Fusion Images to Evaluate the Electrode Positions in Subthalamic Nucleus After Deep-Brain Stimulation. Neurosurgery 2010; 66:1193-202; discussion 1202. [DOI: 10.1227/01.neu.0000369190.46510.42] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Masahiro Shin
- Service de Neurochirurgie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France, and Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Marcello Faria Penholate
- Service de Neurochirurgie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Jean-Pascal Lefaucheur
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Jean-Marc Gurruchaga
- Service de Neurochirurgie, Service de Neurologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Pierre Brugieres
- Service de Neuroradiologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Jean-Paul Nguyen
- Service de Neurochirurgie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
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Suzuki K, Masukawa A, Aoki S, Arai Y, Ueno E. A new coordinates system for cranial organs using magnetic resonance imaging. Acta Otolaryngol 2010; 130:568-75. [PMID: 19916897 DOI: 10.3109/00016480903317473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION We developed a new coordinates system for magnetic resonance imaging (MRI) that utilizes the labyrinth and eyeballs as references to measure the spatial arrangement of cranial organs, and we verified its usefulness by observing small structures in the labyrinth in 39 ears from 33 patients. Our new coordinates system could be used for stereotactic analysis of cranial organs in MRI. OBJECTIVES To research semicircular canal anatomy in healthy organisms, we propose a method that employs references visible on MRI for stereotactic measurement of cranial structures, and we evaluated the usefulness of our method. METHODS Using the new coordinates system and vector analysis, we calculated angles among the semicircular canals and sagittal head plane from MRI volume data containing temporal bone and orbit. RESULTS The angle between the anterior semicircular canal plane and sagittal plane was 35.3 +/- 4.1 degrees; posterior semicircular canal plane and sagittal plane, 50.9 +/- 4.7 degrees; and horizontal semicircular canal plane and sagittal plane, 90.4 +/- 7.0 degrees. The angle between the anterior and posterior semicircular canal planes was 95.1 +/- 4.2 degrees; anterior and horizontal semicircular canal planes, 92.3 +/- 7.5 degrees; and posterior and horizontal semicircular canal planes, 93.5 +/- 4.9 degrees.
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Affiliation(s)
- Kazufumi Suzuki
- Department of Radiology, Medical Center East, Tokyo Women's Medical University, Tokyo, Japan.
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Abstract
Functional neurosurgery involves precise surgical targeting of anatomic structures to modulate neurologic function. From its conception, advances in the surgical treatment of movement disorders have been intertwined with developments in medical imaging, culminating in the use of stereotactic magnetic resonance imaging (MRI). Meticulous attention to detail during image acquisition, direct anatomic localization, and planning of the initial surgical trajectory allows the surgeon to reach the desired anatomic and functional target with the initial trajectory in most cases, thus reducing the need for multiple passes through the brain, and the associated risk of hemorrhage and functional deficit. This philosophy is of paramount importance in a procedure that is primarily aimed at improving quality of life. Documentation of electrode contact location by means of stereotactic imaging is essential to audit surgical targeting accuracy and to further the knowledge of structure-to-function relationships within the human brain.
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Assessment of the variability in the anatomical position and size of the subthalamic nucleus among patients with advanced Parkinson's disease using magnetic resonance imaging. Acta Neurochir (Wien) 2010; 152:201-10; discussion 210. [PMID: 19806309 DOI: 10.1007/s00701-009-0514-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 09/08/2009] [Indexed: 12/23/2022]
Abstract
PURPOSE Targeting of the subthalamic nucleus (STN) during deep brain stimulation (DBS) surgery using standard atlas coordinates is used in some centers. Such coordinates are accurate for only a subgroup of patients, and subgroup size depends on the extent of inter-individual variation in STN position/size and degree to which atlas represents average anatomical relations. Few studies have addressed this issue. METHODS Sixty-two axial T(2)-weighted magnetic resonance (MR) images of the brain (1.5 T) were obtained before STN-DBS in 62 patients (37 males) with Parkinson's disease using a protocol optimized for STN visualization. Image distortion was within sub-millimeter range. Midcommissural point (MCP)-derived coordinates of STN borders, STN center, and other brain landmarks were obtained using stereotactic software. MR-derived measurements were compared to Schaltenbrand and Wahren Atlas. RESULTS We evaluated 117 best-visualized STNs. STN dimensions and coordinates of its center were highly variable. STN lateral coordinate ranged 8.7 mm-14.5 mm from MCP, A-P coordinate 3.5 mm posterior to 0.5 mm anterior to MCP, and vertical coordinate 1.3 mm-6 mm below MCP. The antero-posterior nucleus dimension varied by 8 mm and lateral-medial dimension by 5.8 mm. Differences between mean values of MR-derived data sets and Atlas values were statistically significant but moderate, excluding AC-PC length, for which the Atlas value was below the 1st percentile of the MR data set. The STN lateral coordinate strongly correlated with the width of the third ventricle (r = 0.73, p < 0.001). CONCLUSIONS It is now possible to directly evaluate STNs at 1.5 T with minimal image distortion, which reveals variation in STN position and dimensions in the range of nucleus size. This puts under question the rationale of use of standard STN coordinates during DBS surgery.
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Groiss SJ, Wojtecki L, Südmeyer M, Schnitzler A. Deep brain stimulation in Parkinson's disease. Ther Adv Neurol Disord 2009; 2:20-8. [PMID: 21180627 PMCID: PMC3002606 DOI: 10.1177/1756285609339382] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
During the last 15 years deep brain stimulation (DBS) has been established as a highly-effective therapy for advanced Parkinson's disease (PD). Patient selection, stereotactic implantation, postoperative stimulator programming and patient care requires a multi-disciplinary team including movement disorders specialists in neurology and functional neurosurgery. To treat medically refractory levodopa-induced motor complications or resistant tremor the preferred target for high-frequency DBS is the subthalamic nucleus (STN). STN-DBS results in significant reduction of dyskinesias and dopaminergic medication, improvement of all cardinal motor symptoms with sustained long-term benefits, and significant improvement of quality of life when compared with best medical treatment. These benefits have to be weighed against potential surgery-related adverse events, device-related complications, and stimulus-induced side effects. The mean disease duration before initiating DBS in PD is currently about 13 years. It is presently investigated whether the optimal timing for implantation may be at an earlier disease-stage to prevent psychosocial decline and to maintain quality of life for a longer period of time.
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Affiliation(s)
- S. J. Groiss
- Department of Neurology, Center for Movement Disorders and Neuromodulation,
Heinrich-Heine-University of Düsseldorf, Germany, Institute of
Clinical Neuroscience and Medical Psychology, Heinrich-Heine-University of
Düsseldorf, Germany
| | - L. Wojtecki
- Department of Neurology, Center for Movement Disorders and Neuromodulation,
Heinrich-Heine-University of Düsseldorf, Germany, Institute of
Clinical Neuroscience and Medical Psychology, Heinrich-Heine-University of
Düsseldorf, Germany
| | - M. Südmeyer
- Department of Neurology, Center for Movement Disorders and Neuromodulation,
Heinrich-Heine-University of Düsseldorf, Germany, Institute of
Clinical Neuroscience and Medical Psychology, Heinrich-Heine-University of
Düsseldorf, Germany
| | - A. Schnitzler
- Professor in Neurology, Director of the Institute of Clinical Neuroscience
and Medical Psychology, Heinrich-Heine-University Düsseldorf,
Germany, Department of Neurology, Center for Movement Disorders and
Neuromodulation, Heinrich-Heine-University Düsseldorf, Germany
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Toda H, Sawamoto N, Hanakawa T, Saiki H, Matsumoto S, Okumura R, Ishikawa M, Fukuyama H, Hashimoto N. A novel composite targeting method using high-field magnetic resonance imaging for subthalamic nucleus deep brain stimulation. J Neurosurg 2009; 111:737-45. [PMID: 19326982 DOI: 10.3171/2008.12.jns0861] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Accurate localization of the subthalamic nucleus (STN) is important for proper placement of the electrodes in deep brain stimulation (DBS) surgery for patients with advanced Parkinson disease. The authors evaluated the accuracy of our modified composite targeting method and the value of using high-field MR imaging for targeting the STN. METHODS Thirteen patients with advanced Parkinson disease underwent bilateral STN DBS based on 3-T MR imaging, and 13 patients underwent surgery based on 1.5-T MR imaging. By sequentially referring to the postmammillary commissure, the red nucleus, the mammillothalamic tract, and the STN, the modified composite targeting method determined the stereotactic coordinates for targeting the STN. The accuracy and efficacy of the composite targeting method and 3-T MR imaging were evaluated by using the intraoperative microelectrode recording, the postoperative imaging study, and the postoperative clinical improvement. RESULTS The landmark structures for targeting the STN were visualized clearly with 3-T MR imaging. The mean (+/- SD) path length through the STN of the central track was 4.9 +/- 1.1 mm in the 3-T group and 3.1 +/- 2.0 mm in the 1.5-T group (p < 0.001). Twenty-one (81%) of 26 electrodes were placed in the central track in the 3-T group, whereas 8 (31%) of 26 electrodes were placed in the central track in the 1.5-T group (p = 0.006). The rest of the electrodes were placed in the noncentral optimum track for alleviating parkinsonian motor symptoms. The mean Unified Parkinson's Disease Rating Scale motor part score during off period was reduced by 53% in the 3-T group and by 41% in the 1.5-T group (p = 0.14). The mean reductions of levodopa equivalent daily doses were 48.6% in the 3-T group and 43.7% in the 1.5-T group (p = 0.61). CONCLUSIONS The use of the modified composite targeting method referring to the multiple landmarks with 3-T MR imaging offers reliable and clinically effective target for STN DBS surgery.
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Affiliation(s)
- Hiroki Toda
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Osaka, Japan.
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Voges J, Kiening K, Krauss JK, Nikkhah G, Vesper J. [Neurosurgical standards in deep brain stimulation : consensus recommendations of the German Deep Brain Stimulation Association]. DER NERVENARZT 2009; 80:666-72. [PMID: 19404604 DOI: 10.1007/s00115-009-2698-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgery combining stereotactically guided implantation of brain electrodes in subcortical key structures of the brain with the connection of these brain electrodes to subcutaneously implanted impulse generators is one precondition for the therapeutic application of deep brain stimulation (DBS). During the last 10-15 years minimal requirements concerning this surgery have been formulated, addressing in particular technical equipment and operational procedures and being also in parts supported quantitatively by systematic investigations. Only appropriate patient management, high technical standards and an adequate surgical technique can minimize the frequency of those complications, which are supposed to be directly caused by surgery. High-resolution imaging is the basis for target definition, determination of the surgical approach, documentation of final electrode position and postoperative exclusion of iatrogenic intracerebral haemorrhage. In addition, the quality of treatment planning depends largely on the image processing and viewing possibilities provided by specific planning software. Further issues, for which standards are defined, address electrophysiological and clinical examinations to be performed intraoperatively and general surgical measures, which should be considered during implantation of DBS systems. This review summarizes and evaluates requirements imposed on the aforementioned system components and working steps, taking into consideration data from the literature.
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Affiliation(s)
- J Voges
- Universitätsklinik für Stereotaktische Neurochirurgie, Universitätsklinikum A.ö.R., Leipziger Strasse 44, 39120, Magdeburg, Deutschland.
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Determination of Subthalamic Nucleus Location by Quantitative Analysis of Despiked Background Neural Activity From Microelectrode Recordings Obtained During Deep Brain Stimulation Surgery. J Clin Neurophysiol 2008; 25:98-103. [DOI: 10.1097/wnp.0b013e31816b38dd] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Miyagi Y, Shima F, Sasaki T. Brain shift: an error factor during implantation of deep brain stimulation electrodes. J Neurosurg 2007; 107:989-97. [PMID: 17977272 DOI: 10.3171/jns-07/11/0989] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to focus on the tendency of brain shift during stereotactic neurosurgery and the shift's impact on the unilateral and bilateral implantation of electrodes for deep brain stimulation (DBS). METHODS Eight unilateral and 10 bilateral DBS electrodes at 10 nuclei ventrales intermedii and 18 subthalamic nuclei were implanted in patients at Kaizuka Hospital with the aid of magnetic resonance (MR) imaging-guided and microelectrode-guided methods. Brain shift was assessed as changes in the 3D coordinates of the anterior and posterior commissures (AC and PC) with MR images before and immediately after the implantation surgery. The positions of the implanted electrodes, based on the midcommissural point and AC-PC line, were measured both on x-ray films (virtual position) during surgery and the postoperative MR images (actual position) obtained on the 7th day postoperatively. RESULTS Contralateral and posterior shift of the AC and PC were the characteristics of unilateral and bilateral procedures, respectively. The authors suggest the following. 1) The first unilateral procedure elicits a unilateral air invasion, resulting in a contralateral brain shift. 2) During the second procedure in the bilateral surgery, the contralateral shift is reset to the midline and, at the same time, the anteroposterior support by the contralateral hemisphere against gravity is lost due to a bilateral air invasion, resulting in a significant posterior (caudal) shift. CONCLUSIONS To note the tendency of the brain to shift is very important for accurate implantation of a DBS electrode or high frequency thermocoagulation, as well as for the prediction of therapeutic and adverse effects of stereotactic surgery.
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Affiliation(s)
- Yasushi Miyagi
- Division of Digital Patient, Digital Medicine Initiative, Kyushu University, Fukuoka, Japan.
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Shin M, Lefaucheur JP, Penholate M, Brugières P, Gurruchaga JM, Nguyen JP. Subthalamic nucleus stimulation in Parkinson's disease: Postoperative CT–MRI fusion images confirm accuracy of electrode placement using intraoperative multi-unit recording. Neurophysiol Clin 2007; 37:457-66. [DOI: 10.1016/j.neucli.2007.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Revised: 08/01/2007] [Accepted: 09/09/2007] [Indexed: 10/22/2022] Open
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Sotiropoulos SN, Steinmetz PN. Assessing the direct effects of deep brain stimulation using embedded axon models. J Neural Eng 2007; 4:107-19. [PMID: 17409485 DOI: 10.1088/1741-2560/4/2/011] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
To better understand the spatial extent of the direct effects of deep brain stimulation (DBS) on neurons, we implemented a geometrically realistic finite element electrical model incorporating anisotropic and inhomogenous conductivities. The model included the subthalamic nucleus (STN), substantia nigra (SN), zona incerta (ZI), fields of Forel H2 (FF), internal capsule (IC) and Medtronic 3387/3389 electrode. To quantify the effects of stimulation, we extended previous studies by using multi-compartment axon models with geometry and orientation consistent with anatomical features of the brain regions of interest. Simulation of axonal firing produced a map of relative changes in axonal activation. Voltage-controlled stimulation, with clinically typical parameters at the dorso-lateral STN, caused axon activation up to 4 mm from the target. This activation occurred within the FF, IC, SN and ZI with current intensities close to the average injected during DBS (3 mA). A sensitivity analysis of model parameters (fiber size, fiber orientation, degree of inhomogeneity, degree of anisotropy, electrode configuration) revealed that the FF and IC were consistently activated. Direct activation of axons outside the STN suggests that other brain regions may be involved in the beneficial effects of DBS when treating Parkinsonian symptoms.
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Affiliation(s)
- Stamatios N Sotiropoulos
- Brain Modeling Laboratory, Harrington Department of Bioengineering, Mail Code 9709, ASU Main Campus, Tempe, AZ 85287, USA.
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Falkenberg JH, McNames J, Favre J, Burchiel KJ. Automatic analysis and visualization of microelectrode recording trajectories to the subthalamic nucleus: preliminary results. Stereotact Funct Neurosurg 2006; 84:35-44; discussion 44-5. [PMID: 16741376 DOI: 10.1159/000093721] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although microelectrode recordings (MER) are commonly used to confirm stereotactic targets during surgery for movement disorders, there is no consensus on whether the additional risks and cost of MER are worth the benefits. This may be due, in part, to the inconsistency and inefficiency of subjective interpretation of MER data that is currently used in practice. We describe several fully automatic visualization methods for MER that efficiently and clearly indicate segments of the microelectrode trajectories with homogeneous neural activity that correspond to expected deep brain nuclei. Specifically we demonstrate that these visualization methods can help identify the subthalamic nucleus in Parkinson's disease patients. These methods have the potential to significantly improve patient outcome by helping neurosurgeons objectively identify target structures more quickly and accurately.
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Affiliation(s)
- Jon Haakon Falkenberg
- Biomedical Signal Processing Laboratory, Electrical and Computer Engineering Department, Portland State University, Portland, Oreg., USA
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Rezai AR, Kopell BH, Gross RE, Vitek JL, Sharan AD, Limousin P, Benabid AL. Deep brain stimulation for Parkinson's disease: Surgical issues. Mov Disord 2006; 21 Suppl 14:S197-218. [PMID: 16810673 DOI: 10.1002/mds.20956] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Numerous factors need to be taken into account when implanting deep brain stimulation (DBS) systems into patients with Parkinson's disease. The surgical procedure itself can be divided into immediate preoperative, intraoperative, and immediate postoperative phases. Preoperative considerations include medication withdrawal issues, stereotactic equipment choices, imaging modalities, and targeting strategy. Intraoperative considerations focus on methods for physiological confirmation of a given target for DBS electrode deployment. Terms such as microelectrode recording, microstimulation, and macrostimulation will be defined to clarify inconsistencies in the literature. Advantages and disadvantages of each technique will be addressed. Furthermore, operative decisions such as staging, choice of electrode and implantable pulse generator, and methods of device fixation will be outlined. Postoperative issues include imaging considerations, including magnetic resonance safety, device-device interactions, and immediate surgical complications pertaining to the DBS procedure. This report outlines answers to a series of questions developed to address all aspects of the DBS surgical procedure and decision-making with a systematic overview of the literature (until mid-2004) and by the expert opinion of the authors. This is a report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society. It outlines answers to a series of questions developed to address all surgical aspects of deep brain stimulation.
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Affiliation(s)
- Ali R Rezai
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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den Dunnen WFA, Staal MJ. Anatomical alterations of the subthalamic nucleus in relation to age: a postmortem study. Mov Disord 2005; 20:893-8. [PMID: 15809991 DOI: 10.1002/mds.20417] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The subthalamic nucleus (STN) is currently the preferred target for chronic electrical high-frequency stimulation in Parkinson's disease. Anatomical determination of the exact position of the STN in the individual patient, using magnetic resonance imaging, remains cumbersome, whereas calculation of the target using a stereotactic atlas bypasses patient interindividual variations in the exact delineation of the STN. The aim of this study was to demonstrate variations in shape and position of the STN during life. In this anatomopathological study, a method was applied to localize the STN in reference to the anterior commissure-posterior commissure line (AC-PC line) in 12 postmortem brains of patients who died of non-neurological diseases. Their age varied from 29 to 84 years. Centers and borders of the STN were macroscopically measured in three spatial orthogonal planes in relation to the AC-PC line, and verified by light microscopy. The AC-PC distance remains almost constant during life (24.4 mm; SD 3.58). With increasing age, the center of the STN tends to move 3.9 mm cranially, 2.6 mm laterally, and 0.2 mm anteriorly. This last result also differs from the position mentioned in the stereotactic brain atlases. The form of the STN also changes. During life, the STN becomes wider in the mediolateral direction and smaller in the superior-inferior and anterior-posterior direction. The shape and spatial position of the STN also change during life. These changes should be taken into account during target determination in deep brain stimulation procedures in Parkinson's disease.
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Schlaier J, Schoedel P, Lange M, Winkler J, Warnat J, Dorenbeck U, Brawanski A. Reliability of atlas-derived coordinates in deep brain stimulation. Acta Neurochir (Wien) 2005; 147:1175-80; discussion 1180. [PMID: 16133776 DOI: 10.1007/s00701-005-0606-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Accepted: 06/28/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND In deep brain stimulation the way to define and localize the optimal target for the individual patient is still under debate. The objective of our study was to investigate the reliability of atlas derived data by comparing them with direct targeting on MR images. METHOD We investigated 28 STN targets in 14 volunteers. The stereotactic coordinates of the dorso-lateral subthalamic nucleus (STN), were determined in 5 different ways for both STNs of each individual volunteer: 1. directly, on axial T2WI spin echo slices, 2. directly, on coronal T2WI spin echo slices and after fusion of data sets: 3. indirectly, on an axial atlas plate, 4. indirectly, on a coronal atlas plate, 5. indirectly, 12 mm lateral, 3 mm posterior and 3 mm inferior to mid-AC-PC. FINDINGS The differences between MRI derived targets on axial vs. coronal slices were not statistically significant. After detection of the atlas derived targets the resulting x-coordinates were found more lateral than after direct detection on both, axial and coronal T2-weighted images (p < 0.001). On axial images y-coordinates were located more anterior (p = 0.240) on atlas derived targets and more posterior when target localizations were compared on coronal slices (p < 0.001). z-Coordinates were more superior after atlas targeting compared to MRI targeting (p < 0.001). Differences up to 6.21 mm occurred. CONCLUSIONS Despite the limitations concerning image distortions and slice thickness, direct target planning on MRI, regarding our results, is more reliable than targeting solely based on atlas derived data. Only MRI gives us detailed information about the individual configurations of central structures in every single patient. However, targets, which are not detectable on MRI like the nucleus ventralis intermedius have to be planned using stereotactic atlas information. In these cases intra-operative micro-electrode recording might help to better define the target region.
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Affiliation(s)
- J Schlaier
- Department of Neurosurgery, University of Regensburg, Germany.
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23
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Speelman JD, Bosch DA. Neurosurgical treatment modalities in Parkinson's disease. Mov Disord 2003; 17 Suppl 2:S83-5. [PMID: 11836763 DOI: 10.1002/mds.10067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- J D Speelman
- Neurological and Neurosurgical Departments, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Yelnik J, Damier P, Demeret S, Gervais D, Bardinet E, Bejjani BP, François C, Houeto JL, Arnule I, Dormont D, Galanaud D, Pidoux B, Cornu P, Agid Y. Localization of stimulating electrodes in patients with Parkinson disease by using a three-dimensional atlas-magnetic resonance imaging coregistration method. J Neurosurg 2003; 99:89-99. [PMID: 12854749 DOI: 10.3171/jns.2003.99.1.0089] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to correlate the clinical improvement in patients with Parkinson disease (PD) treated using deep brain stimulation (DBS) of the subthalamic nucleus (STN) with the precise anatomical localization of stimulating electrodes. METHODS Localization was determined by superimposing figures from an anatomical atlas with postoperative magnetic resonance (MR) images obtained in each patient. This approach was validated by an analysis of experimental and clinical MR images of the electrode, and the development of a three-dimensional (3D) atlas-MR imaging coregistration method. The PD motor score was assessed through two contacts for each of two electrodes implanted in 10 patients: the "therapeutic contact" and the "distant contact" (that is, the next but one to the therapeutic contact). Seventeen therapeutic contacts were located within or on the border of the STN, most of which were associated with significant improvement of the four PD symptoms tested. Therapeutic contacts located in other structures (zona incerta, lenticular fasciculus, or midbrain reticular formation) were also linked to a significant positive effect. Stimulation applied through distant contacts located in the STN improved symptoms of PD, whereas that delivered through distant contacts in the remaining structures had variable effects ranging from worsening of symptoms to their improvement. CONCLUSIONS The authors have demonstrated that 3D atlas-MR imaging coregistration is a reliable method for the precise localization of DBS electrodes on postoperative MR images. In addition, they have confirmed that although the STN is the main target during DBS treatment for PD, stimulation of surrounding regions, particularly the zona incerta or the lenticular fasciculus, can also improve symptoms of PD.
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Affiliation(s)
- Jérôme Yelnik
- Institut National de la Santé et de la Recherche Médicale U289, Hôpital de la Salpêtrière, Paris, France.
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Saint-Cyr JA, Hoque T, Pereira LCM, Dostrovsky JO, Hutchison WD, Mikulis DJ, Abosch A, Sime E, Lang AE, Lozano AM. Localization of clinically effective stimulating electrodes in the human subthalamic nucleus on magnetic resonance imaging. J Neurosurg 2002; 97:1152-66. [PMID: 12450038 DOI: 10.3171/jns.2002.97.5.1152] [Citation(s) in RCA: 203] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors sought to determine the location of deep brain stimulation (DBS) electrodes that were most effective in treating Parkinson disease (PD). METHODS Fifty-four DBS electrodes were localized in and adjacent to the subthalamic nucleus (STN) postoperatively by using magnetic resonance (MR) imaging in a series of 29 patients in whom electrodes were implanted for the treatment of medically refractory PD, and for whom quantitative clinical assessments were available both pre- and postoperatively. A novel MR imaging sequence was developed that optimized visualization of the STN. The coordinates of the tips of these electrodes were calculated three dimensionally and the results were normalized and corrected for individual differences by using intraoperative neurophysiological data (mean 5.13 mm caudal to the midcommissural point [MCP], 8.46 mm inferior to the anterior commissure-posterior commissure [AC-PC], and 10.2 mm lateral to the midline). Despite reported concerns about distortion on the MR image, reconstructions provided consistent data for the localization of electrodes. The neurosurgical procedures used, which were guided by combined neuroimaging and neurophysiological methods, resulted in the consistent placement of DBS electrodes in the subthalamus and mesencephalon such that the electrode contacts passed through the STN and dorsally adjacent fields of Forel (FF) and zona incerta (ZI). The mean location of the clinically effective contacts was in the anterodorsal STN (mean 1.62 mm posterior to the MCP, 2.47 mm inferior to the AC-PC, and 11.72 mm lateral to the midline). Clinically effective stimulation was most commonly directed at the anterodorsal STN, with the current spreading into the dorsally adjacent FF and ZI. CONCLUSIONS The anatomical localization of clinically effective electrode contacts provided in this study yields useful information for the postoperative programming of DBS electrodes.
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Affiliation(s)
- Jean A Saint-Cyr
- Department of Surgery, Division of Neurosurgery, University of Toronto and University Health Network, Toronto, Ontario, Canada.
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Cuny E, Guehl D, Burbaud P, Gross C, Dousset V, Rougier A. Lack of agreement between direct magnetic resonance imaging and statistical determination of a subthalamic target: the role of electrophysiological guidance. J Neurosurg 2002; 97:591-7. [PMID: 12296643 DOI: 10.3171/jns.2002.97.3.0591] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECT The goal of this study was to determine the most suitable procedure(s) to localize the optimal site for high-frequency stimulation of the subthalamic nucleus (STN) for the treatment of advanced Parkinson disease. METHODS Stereotactic coordinates of the STN were determined in 14 patients by using three different methods: direct identification of the STN on coronal and axial T2-weighted magnetic resonance (MR) images and indirect targeting in which the STN coordinates are referred to the anterior commissure-posterior commissure (AC-PC) line, which, itself, is determined either by using stereotactic ventriculography or reconstruction from three-dimensional (3D) MR images. During the surgical procedure, electrode implantation was guided by single-unit microrecordings on multiple parallel trajectories and by clinical assessment of stimulations. The site where the optimal functional response was obtained was considered to be the best target. Computerized tomography scanning was performed 3 days later and the scans were combined with preoperative 3D MR images to transfer the position of the best target to the same system of stereotactic coordinates. An algorithm was designed to convert individual stereotactic coordinates into an all-purpose PC-referenced system for comparing the respective accuracy of each method of targeting, according to the position of the best target. CONCLUSIONS The target that is directly identified by MR imaging is more remote (mainly in the lateral axis) from the site of the optimal functional response than targets obtained using other procedures, and the variability of this method in the lateral and superoinferior axes is greater. In contrast, the target defined by 3D MR imaging is closest to the target of optimal functional response and the variability of this method is the least great. Thus, 3D reconstruction adjusted to the AC-PC line is the most accurate technique for STN targeting, whereas direct visualization of the STN on MR images is the least effective. Electrophysiological guidance makes it possible to correct the inherent inaccuracy of the imaging and surgical techniques and is not designed to modify the initial targeting.
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Affiliation(s)
- Emmanuel Cuny
- Service de Neurochirurgie, Höpital Pellegrin, Bordeaux, France.
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Pollak P, Krack P, Fraix V, Mendes A, Moro E, Chabardes S, Benabid AL. Intraoperative micro- and macrostimulation of the subthalamic nucleus in Parkinson's disease. Mov Disord 2002; 17 Suppl 3:S155-61. [PMID: 11948771 DOI: 10.1002/mds.10158] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Studying the clinical effects induced by electrical stimulation of the subthalamic nucleus (STN) area in a parkinsonian patient under local anesthesia is a mandatory step to determine the precise location of the final chronic electrode. Using multiple microelectrodes, preferably in a concentric parallel array allows a precise mapping of the STN region. The most reliable features to determine the suitable target are stimulation-induced dyskinesias and rigidity decrease at a low intensity without adverse effects or only at far higher intensities. New skills are needed to assess all stimulation-induced effects and interpret them in anatomo-functional terms.
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Affiliation(s)
- Pierre Pollak
- Department of Clinical and Biological Neurosciences, Service de Neurologie, Centre Hospitalier Universitaire de Grenoble, Grenoble, France.
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Voges J, Volkmann J, Allert N, Lehrke R, Koulousakis A, Freund HJ, Sturm V. Bilateral high-frequency stimulation in the subthalamic nucleus for the treatment of Parkinson disease: correlation of therapeutic effect with anatomical electrode position. J Neurosurg 2002; 96:269-79. [PMID: 11838801 DOI: 10.3171/jns.2002.96.2.0269] [Citation(s) in RCA: 225] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECT The goal of this study was to relate the degree of clinical improvement and that of energy consumption to the anatomical position of electrode poles used for long-term stimulation. METHODS The authors conducted a retrospective analysis of 15 consecutive patients in whom targeting of the subthalamic nucleus (STN) had been performed using ventriculography, three-dimensional (3D) magnetic resonance (MR) imaging, and 3D computerized tomography, together with macrostimulation and teleradiographic control of the electrode position. In these patients the follow-up period ranged from 6 to 12 months. Postoperative improvement in contralateral motor symptoms, which was assessed by assigning a lateralized motor subscore of the Unified Parkinson's Disease Rating Scale (UPDRS), and stimulus intensity required for optimal treatment results were correlated with the intracerebral position of the active electrode pole. Bilateral high-frequency stimulation of the STN improved the UPDRS motor score during the medication-off period by an average of 60.5% compared with that at baseline. Repeated transfer of stereotactic coordinates from postoperative teleradiography to treatment-planning MR images documented the proper localization of the most distal electrode pole (pole 0) in the targeted STN. Nevertheless, in most cases the best clinical improvement was achieved using electrode poles that were located several millimeters above the electrode tip. If the relative improvement in motor symptoms was correlated with the required electrical energy for chronic stimulation, the best coefficient was observed for active electrode poles projecting onto white matter dorsal to the STN. CONCLUSIONS This observation makes blocking or activation of large fiber connections arising in the STN or running nearby more likely than electrical interference with cell bodies inside the STN. Anatomical correlates may be the pallidothalamic bundle (including Field H of Forel and the thalamic fascicle), the pallidosubthalamic tract, and/or the zona incerta.
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Affiliation(s)
- Jürgen Voges
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Germany.
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Vayssiere N, Hemm S, Zanca M, Picot MC, Bonafe A, Cif L, Frerebeau P, Coubes P. Magnetic resonance imaging stereotactic target localization for deep brain stimulation in dystonic children. J Neurosurg 2000; 93:784-90. [PMID: 11059658 DOI: 10.3171/jns.2000.93.5.0784] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The actual distortion present in a given series of magnetic resonance (MR) images is difficult to establish. The purpose of this study was to validate an MR imaging-based methodology for stereotactic targeting of the internal globus pallidus during electrode implantation in children in whom general anesthesia had been induced. METHODS Twelve children (mean follow up 1 year) suffering from generalized dystonia were treated with deep brain stimulation by using a head frame and MR imaging. To analyze the influence of distortions at every step of the procedure, the geometrical characteristics of the frame were first controlled using the localizer as a phantom. Then pre- and postoperative coordinates of fixed anatomical landmarks and electrode positions, both determined with the head frame in place, were statistically compared. No significant difference was observed between theoretical and measured dimensions of the localizer (Student's t-test, ¿t¿ > 2.2 for 12 patients) in the x, y, and z directions. No significant differences were observed (Wilcoxon paired-sample test) between the following: 1) pre- and postoperative coordinates of the anterior commissure (AC) (deltax = 0.3+/-0.29 mm and deltay = 0.34+/-0.32 mm) and posterior commissure (PC) (deltax = 0.15+/-0.18 mm and deltay = 0.34+/-0.25 mm); 2) pre- and postoperative AC-PC distance (deltaL = 0.33+/-0.22 mm); and 3) preoperative target and final electrode position coordinates (deltax = 0.24+/-0.22 mm; deltay = 0.19+/-0.16 mm). CONCLUSIONS In the authors' center, MR imaging distortions did not induce detectable errors during stereotactic surgery in dystonic children. Target localization and electrode implantation could be achieved using MR imaging alone after induction of general anesthesia. The remarkable postoperative improvement in these patients confirmed the accuracy of the procedure (Burke-Marsden-Fahn Dystonia Rating Scale score delta = -83.8%).
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Affiliation(s)
- N Vayssiere
- Department of Pediatric Neurosurgery, University Hospital, Montpellier, France
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