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Varga I, Bakstein E, Gilmore G, May J, Novak D. Statistical segmentation model for accurate electrode positioning in Parkinson's deep brain stimulation based on clinical low-resolution image data and electrophysiology. PLoS One 2024; 19:e0298320. [PMID: 38483943 PMCID: PMC10939223 DOI: 10.1371/journal.pone.0298320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/22/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Deep Brain Stimulation (DBS), applying chronic electrical stimulation of subcortical structures, is a clinical intervention applied in major neurologic disorders. In order to achieve a good clinical effect, accurate electrode placement is necessary. The primary localisation is typically based on presurgical MRI imaging, often followed by intra-operative electrophysiology recording to increase the accuracy and to compensate for brain shift, especially in cases where the surgical target is small, and there is low contrast: e.g., in Parkinson's disease (PD) and in its common target, the subthalamic nucleus (STN). METHODS We propose a novel, fully automatic method for intra-operative surgical navigation. First, the surgical target is segmented in presurgical MRI images using a statistical shape-intensity model. Next, automated alignment with intra-operatively recorded microelectrode recordings is performed using a probabilistic model of STN electrophysiology. We apply the method to a dataset of 120 PD patients with clinical T2 1.5T images, of which 48 also had available microelectrode recordings (MER). RESULTS The proposed segmentation method achieved STN segmentation accuracy around dice = 0.60 compared to manual segmentation. This is comparable to the state-of-the-art on low-resolution clinical MRI data. When combined with electrophysiology-based alignment, we achieved an accuracy of 0.85 for correctly including recording sites of STN-labelled MERs in the final STN volume. CONCLUSION The proposed method combines image-based segmentation of the subthalamic nucleus with microelectrode recordings to estimate their mutual location during the surgery in a fully automated process. Apart from its potential use in clinical targeting, the method can be used to map electrophysiological properties to specific parts of the basal ganglia structures and their vicinity.
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Affiliation(s)
- Igor Varga
- Department of Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
- Czech Centre for Phenogenomics, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Eduard Bakstein
- Department of Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
- National Institute of Mental Health, Klecany, Czech Republic
| | - Greydon Gilmore
- Movement Disorder Centre, University Hospital, University of Western Ontario, Ontario, Canada
| | - Jaromir May
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Daniel Novak
- Department of Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
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Rajabian A, Vinke S, Candelario-Mckeown J, Milabo C, Salazar M, Nizam AK, Salloum N, Hyam J, Akram H, Joyce E, Foltynie T, Limousin P, Hariz M, Zrinzo L. Accuracy, precision, and safety of stereotactic, frame-based, intraoperative MRI-guided and MRI-verified deep brain stimulation in 650 consecutive procedures. J Neurosurg 2023; 138:1702-1711. [PMID: 36308483 DOI: 10.3171/2022.8.jns22968] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Suboptimal lead placement is one of the most common indications for deep brain stimulation (DBS) revision procedures. Confirming lead placement in relation to the visible anatomical target with dedicated stereotactic imaging before terminating the procedure can mitigate this risk. In this study, the authors examined the accuracy, precision, and safety of intraoperative MRI (iMRI) to both guide and verify lead placement during frame-based stereotactic surgery. METHODS A retrospective analysis of 650 consecutive DBS procedures for targeting accuracy, precision, and perioperative complications was performed. Frame-based lead placement took place in an operating room equipped with an MRI machine using stereotactic images to verify lead placement before removing the stereotactic frame. Immediate lead relocation was performed when necessary. Systematic analysis of the targeting error was calculated. RESULTS Verification of 1201 DBS leads with stereotactic MRI was performed in 643 procedures and with stereotactic CT in 7. The mean ± SD of the final targeting error was 0.9 ± 0.3 mm (range 0.1-2.3 mm). Anatomically acceptable lead placement was achieved with a single brain pass for 97% (n = 1164) of leads; immediate intraoperative relocation was performed in 37 leads (3%) to obtain satisfactory anatomical placement. General anesthesia was used in 91% (n = 593) of the procedures. Hemorrhage was noted after 4 procedures (0.6%); 3 patients (0.4% of procedures) presented with transient neurological symptoms, and 1 experienced delayed cognitive decline. Two bleeds coincided with immediate relocation (2 of 37 leads, 5.4%), which contrasts with hemorrhage in 2 (0.2%) of 1164 leads implanted on the first pass (p = 0.0058). Three patients had transient seizures in the postoperative period. The seizures coincided with hemorrhage in 2 of these patients and with immediate lead relocation in the other. There were 21 infections (3.2% of procedures, 1.5% in 3 months) leading to hardware removal. Delayed (> 3 months) retargeting of 6 leads (0.5%) in 4 patients (0.6% of procedures) was performed because of suboptimal stimulation benefit. There were no MRI-related complications, no permanent motor deficits, and no deaths. CONCLUSIONS To the authors' knowledge, this is the largest series reporting the use of iMRI to guide and verify lead location during DBS surgery. It demonstrates a high level of accuracy, precision, and safety. Significantly higher hemorrhage was encountered when multiple brain passes were required for lead implantation, although none led to permanent deficit. Meticulous audit and calibration can improve precision and maximize safety.
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Affiliation(s)
- Ali Rajabian
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
- 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and
| | - Saman Vinke
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Joseph Candelario-Mckeown
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Catherine Milabo
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Maricel Salazar
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Abdul Karim Nizam
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Nadia Salloum
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Jonathan Hyam
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
- 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and
| | - Harith Akram
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
- 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and
| | - Eileen Joyce
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Thomas Foltynie
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Patricia Limousin
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
| | - Marwan Hariz
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
- 3Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Ludvic Zrinzo
- 1Department of Clinical and Movement Neurosciences, Functional Neurosurgery Unit, University College London, Institute of Neurology, Queen Square, London, United Kingdom
- 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and
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Baláž M, Búřil J, Jurková T, Koriťáková E, Hrabovský D, Kunst J, Bártová P, Chrastina J. Intraoperative electrophysiological monitoring determines the final electrode position for pallidal stimulation in dystonia patients. Front Surg 2023; 10:1206721. [PMID: 37284558 PMCID: PMC10239835 DOI: 10.3389/fsurg.2023.1206721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
Background Bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective treatment for refractory dystonia. Neuroradiological target and stimulation electrode trajectory planning with intraoperative microelectrode recordings (MER) and stimulation are used. With improving neuroradiological techniques, the need for MER is in dispute mainly because of the suspected risk of hemorrhage and the impact on clinical post DBS outcome. Objective The aim of the study is to compare the preplanned GPi electrode trajectories with final trajectories selected for electrode implantation after electrophysiological monitoring and to discuss the factors potentially responsible for differences between preplanned and final trajectories. Finally, the potential association between the final trajectory selected for electrode implantation and clinical outcome will be analyzed. Methods Forty patients underwent bilateral GPi DBS (right-sided implants first) for refractory dystonia. The relationship between preplanned and final trajectories (MicroDrive system) was correlated with patient (gender, age, dystonia type and duration) and surgery characteristics (anesthesia type, postoperative pneumocephalus) and clinical outcome measured using CGI (Clinical Global Impression parameter). The correlation between the preplanned and final trajectories together with CGI was compared between patients 1-20 and 21-40 for the learning curve effect. Results The trajectory selected for definitive electrode implantation matched the preplanned trajectory in 72.5% and 70% on the right and left side respectively; 55% had bilateral definitive electrodes implanted along the preplanned trajectories. Statistical analysis did not confirm any of the studied factors as predictor of the difference between the preplanned and final trajectories. Also no association between CGI and final trajectory selected for electrode implantation in the right/left hemisphere has been proven. The percentages of final electrodes implanted along the preplanned trajectory (the correlation between anatomical planning and intraoperative electrophysiology results) did not differ between patients 1-20 and 21-40. Similarly, there were no statistically significant differences in CGI (clinical outcome) between patients 1-20 and 21-40. Conclusion The final trajectory selected after electrophysiological study differed from the preplanned trajectory in a significant percentage of patients. No predictor of this difference was identified. The anatomo-electrophysiological difference was not predictive of the clinical outcome (as measured using CGI parameter).
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Affiliation(s)
- Marek Baláž
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jiří Búřil
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Tereza Jurková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Eva Koriťáková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Dušan Hrabovský
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jonáš Kunst
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petra Bártová
- Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czechia
| | - Jan Chrastina
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
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Kähkölä J, Lahtinen M, Keinänen T, Katisko J. Stimulation of the Presupplementary Motor Area Cluster of the Subthalamic Nucleus Predicts More Consistent Clinical Outcomes. Neurosurgery 2022; 92:1058-1065. [PMID: 36700693 DOI: 10.1227/neu.0000000000002292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/05/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The development of diffusion tensor imaging and tractography has raised increasing interest in the functional targeting of deep brain stimulation of the subthalamic nucleus (STN) in Parkinson disease. OBJECTIVE To study, using deterministic tractography, the functional subdivisions of the STN and hyperdirect white matter connections located between the STN and the medial frontal cortex, especially the presupplementary motor area (preSMA), SMA, primary motor area (M1), and dorsolateral premotor cortex, and to study retrospectively whether this information correlates with clinical outcome. METHODS Twenty-two patients with Parkinson disease who underwent STN deep brain stimulation were analyzed. Using 3 T MR images, the medial frontal cortex was manually segmented into preSMA, SMA, M1, and dorsolateral premotor cortex, which were then used to determine the functional subdivisions of the lateral border of the STN. The intersectional quantities of the volume of activated tissue (VAT) and the hyperdirect white matter connections were calculated. The results were combined with clinical data including unilateral 12-month postoperative motor outcome and levodopa equivalent daily dose. RESULTS Stimulated clusters of the STN were connected mostly to the cortical SMA and preSMA regions. Patients with primarily preSMA cluster stimulation (presmaVAT% ≥ 50%) had good responses to the treatment with unilateral motor improvement over 40% and levodopa equivalent daily dose reduction over 60%. Larger VAT was not found to correlate with better patient outcomes. CONCLUSION Our study is the first to suggest that stimulating, predominantly, the STN cluster where preSMA hyperdirect pathways are located, could be predictive of more consistent treatment results.
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Affiliation(s)
- Johannes Kähkölä
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Maija Lahtinen
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland.,Neurocenter, Oulu University Hospital, Oulu, Finland
| | - Tuija Keinänen
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland.,Neurocenter, Oulu University Hospital, Oulu, Finland
| | - Jani Katisko
- Oulu Research Group of Advanced Surgical Technologies and Physics - ORGASTP, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland.,Neurocenter, Oulu University Hospital, Oulu, Finland
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Pearce P, Bulluss K, Xu SS, Kim B, Milicevic M, Perera T, Thevathasan W. How accurately are subthalamic nucleus electrodes implanted relative to the ideal stimulation location for Parkinson's disease? PLoS One 2021; 16:e0254504. [PMID: 34264988 PMCID: PMC8282046 DOI: 10.1371/journal.pone.0254504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 06/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The efficacy of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) depends on how closely electrodes are implanted relative to an individual's ideal stimulation location. Yet, previous studies have assessed how closely electrodes are implanted relative to the planned location, after homogenizing data to a reference. Thus here, we measured how accurately electrodes are implanted relative to an ideal, dorsal STN stimulation location, assessed on each individual's native imaging. This measure captures not only the technical error of stereotactic implantation but also constraints imposed by planning a suitable trajectory. METHODS This cross-sectional study assessed 226 electrodes in 113 consecutive PD patients implanted with bilateral STN-DBS by experienced clinicians utilizing awake, microelectrode guided, surgery. The error (Euclidean distance) between the actual electrode trajectory versus a nominated ideal, dorsal STN stimulation location was determined in each hemisphere on native imaging and predictive factors sought. RESULTS The median electrode location error was 1.62 mm (IQR = 1.23 mm). This error exceeded 3 mm in 28/226 electrodes (12.4%). Location error did not differ between hemispheres implanted first or second, suggesting brain shift was minimised. Location error did not differ between electrodes positioned with (48/226), or without, a preceding microelectrode trajectory shift (suggesting such shifts were beneficial). There was no relationship between location error and case order, arguing against a learning effect. DISCUSSION/CONCLUSION The proximity of STN-DBS electrodes to a nominated ideal, dorsal STN, stimulation location is highly variable, even when implanted by experienced clinicians with brain shift minimized, and without evidence of a learning effect. Using this measure, we found that assessments on awake patients (microelectrode recordings and clinical examination) likely yielded beneficial intraoperative decisions to improve positioning. In many patients the error is likely to have reduced therapeutic efficacy. More accurate methods to implant STN-DBS electrodes relative to the ideal stimulation location are needed.
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Affiliation(s)
- Patrick Pearce
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Kristian Bulluss
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Neurosurgery, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - San San Xu
- Bionics Institute, East Melbourne, Victoria, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, Victoria, Australia
- Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Boaz Kim
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | | | - Thushara Perera
- Bionics Institute, East Melbourne, Victoria, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, Victoria, Australia
| | - Wesley Thevathasan
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Schnitzler A, Mir P, Brodsky MA, Verhagen L, Groppa S, Alvarez R, Evans A, Blazquez M, Nagel S, Pilitsis JG, Pötter-Nerger M, Tse W, Almeida L, Tomycz N, Jimenez-Shahed J, Libionka W, Carrillo F, Hartmann CJ, Groiss SJ, Glaser M, Defresne F, Karst E, Cheeran B, Vesper J. Directional Deep Brain Stimulation for Parkinson's Disease: Results of an International Crossover Study With Randomized, Double-Blind Primary Endpoint. Neuromodulation 2021; 25:817-828. [PMID: 34047410 DOI: 10.1111/ner.13407] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/11/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Published reports on directional deep brain stimulation (DBS) have been limited to small, single-center investigations. Therapeutic window (TW) is used to describe the range of stimulation amplitudes achieving symptom relief without side effects. This crossover study performed a randomized double-blind assessment of TW for directional and omnidirectional DBS in a large cohort of patients implanted with a DBS system in the subthalamic nucleus for Parkinson's disease. MATERIALS AND METHODS Participants received omnidirectional stimulation for the first three months after initial study programming, followed by directional DBS for the following three months. The primary endpoint was a double-blind, randomized evaluation of TW for directional vs. omnidirectional stimulation at three months after initial study programming. Additional data recorded at three- and six-month follow-ups included stimulation preference, therapeutic current strength, Unified Parkinson's Disease Rating Scale (UPDRS) part III motor score, and quality of life. RESULTS The study enrolled 234 subjects (62 ± 8 years, 33% female). TW was wider using directional stimulation in 183 of 202 subjects (90.6%). The mean increase in TW with directional stimulation was 41% (2.98 ± 1.38 mA, compared to 2.11 ± 1.33 mA for omnidirectional). UPDRS part III motor score on medication improved 42.4% at three months (after three months of omnidirectional stimulation) and 43.3% at six months (after three months of directional stimulation) with stimulation on, compared to stimulation off. After six months, 52.8% of subjects blinded to stimulation type (102/193) preferred the period with directional stimulation, and 25.9% (50/193) preferred the omnidirectional period. The directional period was preferred by 58.5% of clinicians (113/193) vs. 21.2% (41/193) who preferred the omnidirectional period. CONCLUSION Directional stimulation yielded a wider TW compared to omnidirectional stimulation and was preferred by blinded subjects and clinicians.
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Affiliation(s)
- Alfons Schnitzler
- Department of Neurology, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Pablo Mir
- Clinical Neurology and Neurophysiology Department, Movement Disorders Unit, Institute of Biomedicine of Seville, Virgen del Rocío University Hospital, CSIC/University of Seville, Seville, Spain.,Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED), Seville, Spain
| | - Matthew A Brodsky
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Leonard Verhagen
- Department of Neurological Sciences, Rush University, Chicago, IL, USA
| | - Sergiu Groppa
- Johannes Gutenberg University of Mainz, Clinic of Neurology, Mainz, Germany
| | - Ramiro Alvarez
- Department of Neurology, Hospital Trias i Pujol, Badalona, Spain
| | - Andrew Evans
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Marta Blazquez
- Department of Neurology, Hospital Universitario Central de Asturias, Spain
| | - Sean Nagel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical Center, New York, NY, USA
| | | | - Winona Tse
- Department of Neurology, Mount Sinai Hospital, New York, NY, USA
| | - Leonardo Almeida
- Department of Neurology, Shands at University of Florida, Gainesville, FL, USA
| | - Nestor Tomycz
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Witold Libionka
- Department of Neurology, Copernicus Hospital, Gdansk, Poland
| | - Fatima Carrillo
- Clinical Neurology and Neurophysiology Department, Movement Disorders Unit, Institute of Biomedicine of Seville, Virgen del Rocío University Hospital, CSIC/University of Seville, Seville, Spain
| | - Christian J Hartmann
- Department of Neurology, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Martin Glaser
- Department of Neurosurgery, Johannes Gutenberg University of Mainz, Mainz, Germany
| | | | - Edward Karst
- Abbott, Medical and Clinical Affairs, Plano, TX, USA
| | | | - Jan Vesper
- Department of Neurosurgery, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
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Malaga KA, Costello JT, Chou KL, Patil PG. Atlas-independent, N-of-1 tissue activation modeling to map optimal regions of subthalamic deep brain stimulation for Parkinson disease. NEUROIMAGE-CLINICAL 2020; 29:102518. [PMID: 33333464 PMCID: PMC7736726 DOI: 10.1016/j.nicl.2020.102518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 01/13/2023]
Abstract
Neuroanatomical variations among patients are obscured in atlas-based VTA modeling. N-of-1 neuroanatomical and VTA modeling enables patient-level precision. Mean optimal stimulation is dorsomedial to the STN, near its posterior half. Individual VTAs deviate from optimal stimulation sites to varying degrees. Optimal stimulation sites for rigidity, bradykinesia, and tremor partially overlap.
Background Motor outcomes after subthalamic deep brain stimulation (STN DBS) for Parkinson disease (PD) vary considerably among patients and strongly depend on stimulation location. The objective of this retrospective study was to map the regions of optimal STN DBS for PD using an atlas-independent, fully individualized (N-of-1) tissue activation modeling approach and to assess the relationship between patient-level therapeutic volumes of tissue activation (VTAs) and motor improvement. Methods The stimulation-induced electric field for 40 PD patients treated with bilateral STN DBS was modeled using finite element analysis. Neurostimulation models were generated for each patient, incorporating their individual STN anatomy, DBS lead position and orientation, anisotropic tissue conductivity, and clinical stimulation settings. A voxel-based analysis of the VTAs was then used to map the optimal location of stimulation. The amount of stimulation in specific regions relative to the STN was measured and compared between STNs with more and less optimal stimulation, as determined by their motor improvement scores and VTA. The relationship between VTA location and motor outcome was then assessed using correlation analysis. Patient variability in terms of STN anatomy, active contact position, and VTA location were also evaluated. Results from the N-of-1 model were compared to those from a simplified VTA model. Results Tissue activation modeling mapped the optimal location of stimulation to regions medial, posterior, and dorsal to the STN centroid. These regions extended beyond the STN boundary towards the caudal zona incerta (cZI). The location of the VTA and active contact position differed significantly between STNs with more and less optimal stimulation in the dorsal-ventral and anterior-posterior directions. Therapeutic stimulation spread noticeably more in the dorsal and posterior directions, providing additional evidence for cZI as an important DBS target. There were significant linear relationships between the amount of dorsal and posterior stimulation, as measured by the VTA, and motor improvement. These relationships were more robust than those between active contact position and motor improvement. There was high variability in STN anatomy, active contact position, and VTA location among patients. Spherical VTA modeling was unable to reproduce these results and tended to overestimate the size of the VTA. Conclusion Accurate characterization of the spread of stimulation is needed to optimize STN DBS for PD. High variability in neuroanatomy, stimulation location, and motor improvement among patients highlights the need for individualized modeling techniques. The atlas-independent, N-of-1 tissue activation modeling approach presented in this study can be used to develop and evaluate stimulation strategies to improve clinical outcomes on an individual basis.
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Affiliation(s)
- Karlo A Malaga
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Joseph T Costello
- Department of Electrical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Kelvin L Chou
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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Hwang BY, Mampre D, Mills K, Courtney P, Kim MJ, Butala AA, Anderson WS. Non-staged bilateral Globus Pallidus Internus deep brain stimulation lead revision using intraoperative MRI: a case report and literature review. Br J Neurosurg 2020; 35:301-305. [PMID: 32648480 DOI: 10.1080/02688697.2020.1789556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) lead revision due to suboptimal therapy is common but there is no standardised protocol. We describe a novel technique using iMRI to perform concurrent new Globus Pallidus Internus (GPi) DBS lead implantation and old lead removal in a dystonia patient.Case-description: A 60-year-old woman with medication and neurotoxin-refractory isolated cervical dystonia underwent awake bilateral GPi DBS surgery with MER-guided lead implantation. She initially had a favourable response but later reported suboptimal benefit despite reprogramming. MRI demonstrated suboptimal lead placement and MRI-guided revision surgery under general anesthesia was planned. The goal was to place new leads superior and medial to the existing leads. Using a 1.5 T iMRI and the ClearPoint® NeuroNavigation system, new leads were placed through the existing burr holes, into the new targets with radial errors < 0.08mm bilaterally without crossing the old leads. The old leads were then removed and the new leads connected to the existing pulse generator. The patient tolerated the procedure well and had improved side-effect profile at all contacts at 1-month follow-up. CONCLUSIONS Non-staged iMRI-guided DBS revision surgery under general anesthesia is technically feasible and is an alternative strategy to a staged iMRI-guided revision surgery or an awake MER-guided revision surgery in select patients.
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Affiliation(s)
- Brian Y Hwang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David Mampre
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kelly Mills
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Pamala Courtney
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Min Jae Kim
- Department of Biomedical Engineering and Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ankur A Butala
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Shamir RR, Duchin Y, Kim J, Patriat R, Marmor O, Bergman H, Vitek JL, Sapiro G, Bick A, Eliahou R, Eitan R, Israel Z, Harel N. Microelectrode Recordings Validate the Clinical Visualization of Subthalamic-Nucleus Based on 7T Magnetic Resonance Imaging and Machine Learning for Deep Brain Stimulation Surgery. Neurosurgery 2020; 84:749-757. [PMID: 29800386 DOI: 10.1093/neuros/nyy212] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/26/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a proven and effective therapy for the management of the motor symptoms of Parkinson's disease (PD). While accurate positioning of the stimulating electrode is critical for success of this therapy, precise identification of the STN based on imaging can be challenging. We developed a method to accurately visualize the STN on a standard clinical magnetic resonance imaging (MRI). The method incorporates a database of 7-Tesla (T) MRIs of PD patients together with machine-learning methods (hereafter 7 T-ML). OBJECTIVE To validate the clinical application accuracy of the 7 T-ML method by comparing it with identification of the STN based on intraoperative microelectrode recordings. METHODS Sixteen PD patients who underwent microelectrode-recordings guided STN DBS were included in this study (30 implanted leads and electrode trajectories). The length of the STN along the electrode trajectory and the position of its contacts to dorsal, inside, or ventral to the STN were compared using microelectrode-recordings and the 7 T-ML method computed based on the patient's clinical 3T MRI. RESULTS All 30 electrode trajectories that intersected the STN based on microelectrode-recordings, also intersected it when visualized with the 7 T-ML method. STN trajectory average length was 6.2 ± 0.7 mm based on microelectrode recordings and 5.8 ± 0.9 mm for the 7 T-ML method. We observed a 93% agreement regarding contact location between the microelectrode-recordings and the 7 T-ML method. CONCLUSION The 7 T-ML method is highly consistent with microelectrode-recordings data. This method provides a reliable and accurate patient-specific prediction for targeting the STN.
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Affiliation(s)
| | - Yuval Duchin
- Surgical Information Sciences, Minneapolis, Minnesota.,Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minnesota
| | - Jinyoung Kim
- Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina
| | - Remi Patriat
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minnesota
| | - Odeya Marmor
- Department of Neurobiology, Institute of Medical Research-Israel Canada (IMRIC), The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Hagai Bergman
- Department of Neurobiology, Institute of Medical Research-Israel Canada (IMRIC), The Hebrew University-Hadassah Medical School, Jerusalem, Israel.,Edmond and Lily Safra Center for Brain Sciences, The Hebrew University, Jerusalem, Israel
| | - Jerrold L Vitek
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | - Guillermo Sapiro
- Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina.,Departments of Biomedical Engineering, Computer Science, and Mathematics, Duke University, Durham, North Carolina
| | - Atira Bick
- Department of Radiology, Hadassah Medical Center, Jerusalem, Israel
| | - Ruth Eliahou
- Department of Radiology, Hadassah Medical Center, Jerusalem, Israel
| | - Renana Eitan
- Department of Neurobiology, Institute of Medical Research-Israel Canada (IMRIC), The Hebrew University-Hadassah Medical School, Jerusalem, Israel.,Functional Neuroimaging Laboratory, Brigham and Women's Hospital, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Medical Center, Jerusalem, Israel
| | - Noam Harel
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minnesota
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10
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Structural Imaging and Target Visualization. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Letter to the Editor Regarding "Statistical Shape Analysis of Subthalamic Nucleus in Patients with Parkinson's Disease". World Neurosurg 2019; 128:629. [PMID: 31675769 DOI: 10.1016/j.wneu.2019.03.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/20/2022]
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12
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Park SC, Cha JH, Lee S, Jang W, Lee CS, Lee JK. Deep Learning-Based Deep Brain Stimulation Targeting and Clinical Applications. Front Neurosci 2019; 13:1128. [PMID: 31708729 PMCID: PMC6821714 DOI: 10.3389/fnins.2019.01128] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 10/04/2019] [Indexed: 12/26/2022] Open
Abstract
Background The purpose of the present study was to evaluate deep learning-based image-guided surgical planning for deep brain stimulation (DBS). We developed deep learning semantic segmentation-based DBS targeting and prospectively applied the method clinically. Methods T2∗ fast gradient-echo images from 102 patients were used for training and validation. Manually drawn ground truth information was prepared for the subthalamic and red nuclei with an axial cut ∼4 mm below the anterior–posterior commissure line. A fully convolutional neural network (FCN-VGG-16) was used to ensure margin identification by semantic segmentation. Image contrast augmentation was performed nine times. Up to 102 original images and 918 augmented images were used for training and validation. The accuracy of semantic segmentation was measured in terms of mean accuracy and mean intersection over the union. Targets were calculated based on their relative distance from these segmented anatomical structures considering the Bejjani target. Results Mean accuracies and mean intersection over the union values were high: 0.904 and 0.813, respectively, for the 62 training images, and 0.911 and 0.821, respectively, for the 558 augmented training images when 360 augmented validation images were used. The Dice coefficient converted from the intersection over the union was 0.902 when 720 training and 198 validation images were used. Semantic segmentation was adaptive to high anatomical variations in size, shape, and asymmetry. For clinical application, two patients were assessed: one with essential tremor and another with bradykinesia and gait disturbance due to Parkinson’s disease. Both improved without complications after surgery, and microelectrode recordings showed subthalamic nuclei signals in the latter patient. Conclusion The accuracy of deep learning-based semantic segmentation may surpass that of previous methods. DBS targeting and its clinical application were made possible using accurate deep learning-based semantic segmentation, which is adaptive to anatomical variations.
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Affiliation(s)
- Seong-Cheol Park
- Department of Neurosurgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan, Gangneung, South Korea
| | - Joon Hyuk Cha
- Department of Neurosurgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, South Korea.,School of Medicine, Inha University, Incheon, South Korea
| | - Seonhwa Lee
- Department of Neurosurgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Bio-Convergence Engineering, College of Health Science, Korea University, Seoul, South Korea
| | - Wooyoung Jang
- Department of Neurology, Gangneung Asan Hospital, University of Ulsan, Gangneung, South Korea
| | - Chong Sik Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Jung Kyo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
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13
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Hoch MJ, Bruno MT, Faustin A, Cruz N, Mogilner AY, Crandall L, Wisniewski T, Devinsky O, Shepherd TM. 3T MRI Whole-Brain Microscopy Discrimination of Subcortical Anatomy, Part 2: Basal Forebrain. AJNR Am J Neuroradiol 2019; 40:1095-1105. [PMID: 31196861 DOI: 10.3174/ajnr.a6088] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 04/22/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE The basal forebrain contains multiple structures of great interest to emerging functional neurosurgery applications, yet many neuroradiologists are unfamiliar with this neuroanatomy because it is not resolved with current clinical MR imaging. MATERIALS AND METHODS We applied an optimized TSE T2 sequence to washed whole postmortem brain samples (n = 13) to demonstrate and characterize the detailed anatomy of the basal forebrain using a clinical 3T MR imaging scanner. We measured the size of selected internal myelinated pathways and measured subthalamic nucleus size, oblique orientation, and position relative to the intercommissural point. RESULTS We identified most basal ganglia and diencephalon structures using serial axial, coronal, and sagittal planes relative to the intercommissural plane. Specific oblique image orientations demonstrated the positions and anatomic relationships for selected structures of interest to functional neurosurgery. We observed only 0.2- to 0.3-mm right-left differences in the anteroposterior and superoinferior length of the subthalamic nucleus (P = .084 and .047, respectively). Individual variability for the subthalamic nucleus was greatest for angulation within the sagittal plane (range, 15°-37°), transverse dimension (range, 2-6.7 mm), and most inferior border (range, 4-7 mm below the intercommissural plane). CONCLUSIONS Direct identification of basal forebrain structures in multiple planes using the TSE T2 sequence makes this challenging neuroanatomy more accessible to practicing neuroradiologists. This protocol can be used to better define individual variations relevant to functional neurosurgical targeting and validate/complement advanced MR imaging methods being developed for direct visualization of these structures in living patients.
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Affiliation(s)
- M J Hoch
- From the Department of Radiology and Imaging Sciences, (M.J.H.), Emory University, Atlanta, Georgia
| | - M T Bruno
- Departments of Radiology (M.T.B., N.C., T.M.S.)
| | | | - N Cruz
- Departments of Radiology (M.T.B., N.C., T.M.S.)
| | | | - L Crandall
- Neurology (L.C., T.W., O.D.).,SUDC Foundation (L.C., O.D.), New York, New York
| | - T Wisniewski
- Pathology (A.F., T.W.).,Neurology (L.C., T.W., O.D.).,Psychiatry (T.W.), New York University, New York, New York
| | - O Devinsky
- Neurology (L.C., T.W., O.D.).,SUDC Foundation (L.C., O.D.), New York, New York
| | - T M Shepherd
- Departments of Radiology (M.T.B., N.C., T.M.S.) .,Center for Advanced Imaging Innovation and Research (T.M.S.), New York, New York
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14
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Kim J, Duchin Y, Shamir RR, Patriat R, Vitek J, Harel N, Sapiro G. Automatic localization of the subthalamic nucleus on patient-specific clinical MRI by incorporating 7 T MRI and machine learning: Application in deep brain stimulation. Hum Brain Mapp 2019; 40:679-698. [PMID: 30379376 PMCID: PMC6519731 DOI: 10.1002/hbm.24404] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has shown clinical potential for relieving the motor symptoms of advanced Parkinson's disease. While accurate localization of the STN is critical for consistent across-patients effective DBS, clear visualization of the STN under standard clinical MR protocols is still challenging. Therefore, intraoperative microelectrode recordings (MER) are incorporated to accurately localize the STN. However, MER require significant neurosurgical expertise and lengthen the surgery time. Recent advances in 7 T MR technology facilitate the ability to clearly visualize the STN. The vast majority of centers, however, still do not have 7 T MRI systems, and fewer have the ability to collect and analyze the data. This work introduces an automatic STN localization framework based on standard clinical MRIs without additional cost in the current DBS planning protocol. Our approach benefits from a large database of 7 T MRI and its clinical MRI pairs. We first model in the 7 T database, using efficient machine learning algorithms, the spatial and geometric dependency between the STN and its adjacent structures (predictors). Given a standard clinical MRI, our method automatically computes the predictors and uses the learned information to predict the patient-specific STN. We validate our proposed method on clinical T2 W MRI of 80 subjects, comparing with experts-segmented STNs from the corresponding 7 T MRI pairs. The experimental results show that our framework provides more accurate and robust patient-specific STN localization than using state-of-the-art atlases. We also demonstrate the clinical feasibility of the proposed technique assessing the post-operative electrode active contact locations.
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Affiliation(s)
- Jinyoung Kim
- Surgical Information Sciences, Inc.MinneapolisMinnesota
| | - Yuval Duchin
- Surgical Information Sciences, Inc.MinneapolisMinnesota
| | | | - Remi Patriat
- Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesota
| | - Jerrold Vitek
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesota
| | - Noam Harel
- Surgical Information Sciences, Inc.MinneapolisMinnesota
- Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesota
- Department of NeurosurgeryUniversity of MinnesotaMinneapolisMinnesota
| | - Guillermo Sapiro
- Surgical Information Sciences, Inc.MinneapolisMinnesota
- Department of Electrical and Computer EngineeringDuke UniversityDurhamNorth Carolina
- Department of Biomedical EngineeringDuke UniversityDurhamNorth Carolina
- Department of Computer ScienceDuke UniversityDurhamNorth Carolina
- Department of MathematicsDuke UniversityDurhamNorth Carolina
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15
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Duchin Y, Shamir RR, Patriat R, Kim J, Vitek JL, Sapiro G, Harel N. Patient-specific anatomical model for deep brain stimulation based on 7 Tesla MRI. PLoS One 2018; 13:e0201469. [PMID: 30133472 PMCID: PMC6104927 DOI: 10.1371/journal.pone.0201469] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/15/2018] [Indexed: 01/16/2023] Open
Abstract
Objective Deep brain stimulation (DBS) requires accurate localization of the anatomical target structure, and the precise placement of the DBS electrode within it. Ultra-high field 7 Tesla (T) MR images can be utilized to create patient-specific anatomical 3D models of the subthalamic nuclei (STN) to enhance pre-surgical DBS targeting as well as post-surgical visualization of the DBS lead position and orientation. We validated the accuracy of the 7T imaging-based patient-specific model of the STN and measured the variability of the location and dimensions across movement disorder patients. Methods 72 patients who underwent DBS surgery were scanned preoperatively on 7T MRI. Segmentations and 3D volume rendering of the STN were generated for all patients. For 21 STN-DBS cases, microelectrode recording (MER) was used to validate the segmentation. For 12 cases, we computed the correlation between the overlap of the STN and volume of tissue activated (VTA) and the monopolar review for a further validation of the model’s accuracy and its clinical relevancy. Results We successfully reconstructed and visualized the STN in all patients. Significant variability was found across individuals regarding the location of the STN center of mass as well as its volume, length, depth and width. Significant correlations were found between MER and the 7T imaging-based model of the STN (r = 0.86) and VTA-STN overlap and the monopolar review outcome (r = 0.61). Conclusion The results suggest that an accurate visualization and localization of a patient-specific 3D model of the STN can be generated based on 7T MRI. The imaging-based 7T MRI STN model was validated using MER and patient’s clinical outcomes. The significant variability observed in the STN location and shape based on a large number of patients emphasizes the importance of an accurate direct visualization of the STN for DBS targeting. An accurate STN localization can facilitate postoperative stimulation parameters for optimized patient outcome.
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Affiliation(s)
- Yuval Duchin
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States of America
- Surgical Information Sciences, Minneapolis, MN, United States of America
| | - Reuben R. Shamir
- Surgical Information Sciences, Minneapolis, MN, United States of America
| | - Remi Patriat
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States of America
| | - Jinyoung Kim
- Surgical Information Sciences, Minneapolis, MN, United States of America
- Departments of Electrical & Computer Engineering, Computer Science, Biomedical Engineering and Math, Duke University, Durham, NC, United States of America
| | - Jerrold L. Vitek
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States of America
| | - Guillermo Sapiro
- Departments of Electrical & Computer Engineering, Computer Science, Biomedical Engineering and Math, Duke University, Durham, NC, United States of America
| | - Noam Harel
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States of America
- * E-mail:
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16
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Keuken MC, Isaacs BR, Trampel R, van der Zwaag W, Forstmann BU. Visualizing the Human Subcortex Using Ultra-high Field Magnetic Resonance Imaging. Brain Topogr 2018; 31:513-545. [PMID: 29497874 PMCID: PMC5999196 DOI: 10.1007/s10548-018-0638-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/28/2018] [Indexed: 12/15/2022]
Abstract
With the recent increased availability of ultra-high field (UHF) magnetic resonance imaging (MRI), substantial progress has been made in visualizing the human brain, which can now be done in extraordinary detail. This review provides an extensive overview of the use of UHF MRI in visualizing the human subcortex for both healthy and patient populations. The high inter-subject variability in size and location of subcortical structures limits the usability of atlases in the midbrain. Fortunately, the combined results of this review indicate that a large number of subcortical areas can be visualized in individual space using UHF MRI. Current limitations and potential solutions of UHF MRI for visualizing the subcortex are also discussed.
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Affiliation(s)
- M C Keuken
- Integrative Model-Based Cognitive Neuroscience Research Unit, University of Amsterdam, Postbus 15926, 1001NK, Amsterdam, The Netherlands.
- Cognitive Psychology Unit, Institute of Psychology and Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands.
| | - B R Isaacs
- Integrative Model-Based Cognitive Neuroscience Research Unit, University of Amsterdam, Postbus 15926, 1001NK, Amsterdam, The Netherlands
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - R Trampel
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | | | - B U Forstmann
- Integrative Model-Based Cognitive Neuroscience Research Unit, University of Amsterdam, Postbus 15926, 1001NK, Amsterdam, The Netherlands
- Netherlands Institute for Neuroscience, An Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
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17
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Ranjan M, Boutet A, Xu DS, Lozano CS, Kumar R, Fasano A, Kucharczyk W, Lozano AM. Subthalamic Nucleus Visualization on Routine Clinical Preoperative MRI Scans: A Retrospective Study of Clinical and Image Characteristics Predicting Its Visualization. Stereotact Funct Neurosurg 2018; 96:120-126. [PMID: 29847826 DOI: 10.1159/000488397] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/05/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The visualization of the subthalamic nucleus (STN) on magnetic resonance imaging (MRI) is variable. Studies of the contribution of patient-related factors and intrinsic brain volumetrics to STN visualization have not been reported previously. OBJECTIVE To assess the visualization of the STN during deep brain stimulation (DBS) surgery in a clinical setting. METHODS Eighty-two patients undergoing pre-operative MRI to plan for STN DBS for Parkinson disease were retrospectively studied. The visualization of the STN and its borders was assessed and scored by 3 independent observers using a 4-point ordinal scale (from 0 = not seen to 3 = excellent visualization). This measure was then correlated with the patients' clinical information and brain volumes. RESULTS The mean STN visualization scores were 1.68 and 1.63 for the right and left STN, respectively, with a good interobserver reliability (intraclass correlation coefficient: 0.744). Older age and decreased white matter volume were negatively correlated with STN visualization (p < 0.05). CONCLUSION STN visualization is only fair to good on routine MRI with good concordance of interindividual rating. Advancing age and decreased white matter are associated with poor visualization of the STN. Knowledge about factors contributing to poor visualization of the STN could alert a surgeon to modify the imaging strategy to optimize surgical targeting.
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Affiliation(s)
- Manish Ranjan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David S Xu
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rajeev Kumar
- Marine Institute, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Centre and Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Division of Neuroimaging, Department of Medical Imaging, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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18
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Bot M, Schuurman PR, Odekerken VJJ, Verhagen R, Contarino FM, De Bie RMA, van den Munckhof P. Deep brain stimulation for Parkinson's disease: defining the optimal location within the subthalamic nucleus. J Neurol Neurosurg Psychiatry 2018; 89:493-498. [PMID: 29353236 DOI: 10.1136/jnnp-2017-316907] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/12/2017] [Accepted: 11/20/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Individual motor improvement after deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD) varies considerably. Stereotactic targeting of the dorsolateral sensorimotor part of the STN is considered paramount for maximising effectiveness, but studies employing the midcommissural point (MCP) as anatomical reference failed to show correlation between DBS location and motor improvement. The medial border of the STN as reference may provide better insight in the relationship between DBS location and clinical outcome. METHODS Motor improvement after 12 months of 65 STN DBS electrodes was categorised into non-responding, responding and optimally responding body-sides. Stereotactic coordinates of optimal electrode contacts relative to both medial STN border and MCP served to define theoretic DBS 'hotspots'. RESULTS Using the medial STN border as reference, significant negative correlation (Pearson's correlation -0.52, P<0.01) was found between the Euclidean distance from the centre of stimulation to this DBS hotspot and motor improvement. This hotspot was located at 2.8 mm lateral, 1.7 mm anterior and 2.5 mm superior relative to the medial STN border. Using MCP as reference, no correlation was found. CONCLUSION The medial STN border proved superior compared with MCP as anatomical reference for correlation of DBS location and motor improvement, and enabled defining an optimal DBS location within the nucleus. We therefore propose the medial STN border as a better individual reference point than the currently used MCP on preoperative stereotactic imaging, in order to obtain optimal and thus less variable motor improvement for individual patients with PD following STN DBS.
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Affiliation(s)
- Maarten Bot
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - P Richard Schuurman
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Vincent J J Odekerken
- Department of Neurology and Clinical Neurophysiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rens Verhagen
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Fiorella Maria Contarino
- Department of Neurology and Clinical Neurophysiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurology, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Rob M A De Bie
- Department of Neurology and Clinical Neurophysiology, Academic Medical Center, Amsterdam, The Netherlands
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19
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Awake versus Asleep Deep Brain Stimulation Surgery: Technical Considerations and Critical Review of the Literature. Brain Sci 2018; 8:brainsci8010017. [PMID: 29351243 PMCID: PMC5789348 DOI: 10.3390/brainsci8010017] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/08/2018] [Accepted: 01/16/2018] [Indexed: 11/22/2022] Open
Abstract
Advancements in neuroimaging have led to a trend toward direct, image-based targeting under general anesthesia without the use of microelectrode recording (MER) or intraoperative test stimulation, also referred to as “asleep” deep brain stimulation (DBS) surgery. Asleep DBS, utilizing imaging in the form of intraoperative computed tomography (iCT) or magnetic resonance imaging (iMRI), has demonstrated reliable targeting accuracy of DBS leads implanted within the globus pallidus and subthalamic nucleus while also improving clinical outcomes in patients with Parkinson’s disease. In lieu, of randomized control trials, retrospective comparisons between asleep and awake DBS with MER have shown similar short-term efficacy with the potential for decreased complications in asleep cohorts. In lieu of long-term outcome data, awake DBS using MER must demonstrate more durable outcomes with fewer stimulation-induced side effects and lead revisions in order for its use to remain justifiable; although patient-specific factors may also be used to guide the decision regarding which technique may be most appropriate and tolerable to the patient.
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20
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Ispierto L, Muñoz J, Cladellas JM, Cuadras P, Capellades J, Latorre P, Dávalos A, Vancamp T, Álvarez R. Post-Operative Localization of Deep Brain Stimulation Electrodes in the Subthalamus Using Transcranial Sonography. Neuromodulation 2017; 21:574-581. [PMID: 29178240 DOI: 10.1111/ner.12733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/19/2017] [Accepted: 06/16/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The correct positioning of deep brain stimulation electrodes determines the success of surgery. In this study, we attempt to validate transcranial sonography (TCS) as a method for early postoperative confirmation of electrode location in the subthalamic nucleus (STN). MATERIALS AND METHODS Nineteen patients diagnosed with Parkinson's disease were enrolled in the study. Postoperative TCS was applied to measure the distance between the implanted electrodes and the third ventricle in the axial plane. Whether the electrodes were positioned within or outside the substantia nigra (SN) was evaluated through measurements in the coronal plane. The obtained metrics through TCS were compared with those from postoperative computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS A statistically significant correlation between distances from electrode to third ventricle by TCS and CT/MRI (r = 0.75, p < 0.01) was observed. Distances from third ventricle to electrodes tips were different when sonographically they showed to be inside or outside the SN (p < 0.01). A cut-off value of 8.85mm in these distances was the most sensitive (100%) and specific (90.5%) to predict if electrodes were positioned inside the SN (CI 95% 0.81-10.30, p = 0.001). CONCLUSIONS Transcranial sonography is a useful technique to reliably identify targeted positioning of deep brain stimulation electrodes in or out of the SN.
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Affiliation(s)
- Lourdes Ispierto
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Jorge Muñoz
- Department of Neurosurgery and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Josep Maria Cladellas
- Department of Neurosurgery and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Patricia Cuadras
- Department of Radiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Jaume Capellades
- Image Diagnosis Institute, Badalona, Spain.,Department of Medical Imaging Consorci MAR Parc de Salut, Barcelona, Spain
| | - Pilar Latorre
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Antoni Dávalos
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Tim Vancamp
- BRAI2N, St. Augustinus Hospital, Wilrijk, Belgium
| | - Ramiro Álvarez
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
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Shenai MB, Patel DM, Romeo A, Whisenhunt JD, Walker HC, Guthrie S, Guthrie BL. The Relationship of Electrophysiologic Subthalamic Nucleus Length as a Predictor of Outcomes in Deep Brain Stimulation for Parkinson Disease. Stereotact Funct Neurosurg 2017; 95:341-347. [PMID: 28982098 DOI: 10.1159/000478023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 06/05/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intraoperative measurement of subthalamic nucleus (STN) width through microelectrode recording (MER) is a common proxy for optimal electrode location during deep brain stimulation (DBS) surgery for Parkinson disease. We assessed whether the MER-determined STN width is a predictor of postoperative Unified Parkinson Disease Rating Scale (UPDRS) improvement. METHODS Records were reviewed for patients who underwent single-sided STN DBS placement for Parkinson disease between 2005 and 2010 at the UAB Medical Center. Reviews of preoperative and 3-month postoperative UPDRS part III, intraoperative MER records, and postoperative MRI scans were conducted. RESULTS The final cohort consisted of 73 patients (mean age 59 ± 9.7 years, length of disease 13 ± 9.7 years). STN widths were defined as depths associated with increased background activity and motor-driven, spiking action potentials on MER. The mean contralateral UPDRS improvement was 58% (± 24). The mean STN width was 5.1 mm (± 1.6, min = 0.0, max = 8.7). No significant relationship between STN width and UPDRS improvement was found, with and without AC-PC normalization (R2 < 0.05). CONCLUSION This analysis raises questions about seeking the maximal electrophysiological width of STN as a proxy for optimal outcome in DBS for PD. We suggest this strategy for DBS placement in Parkinson disease be subject to more robust prospective investigation.
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Affiliation(s)
- Mahesh B Shenai
- Inova Medical Group Department of Neurosurgery, Fairfax, VA, USA
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Tamir I, Marmor-Levin O, Eitan R, Bergman H, Israel Z. Posterolateral Trajectories Favor a Longer Motor Domain in Subthalamic Nucleus Deep Brain Stimulation for Parkinson Disease. World Neurosurg 2017; 106:450-461. [DOI: 10.1016/j.wneu.2017.06.178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 01/08/2023]
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23
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Xie L, Rong J, Li Q. A Novel Method for Constructing Histological Section Datasets of the Basal Ganglia in Digitized Human Brain. Anat Rec (Hoboken) 2016; 300:1011-1021. [PMID: 27981802 DOI: 10.1002/ar.23526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/14/2016] [Accepted: 09/01/2016] [Indexed: 11/08/2022]
Abstract
To investigate the construction of the histological section datasets in the basal ganglia of digitized human brain to provide a reference for the meso-level histological data acquisition. A fresh adult brain from a cadaver with no neurological disease was selected, and tissue blocks of the basal ganglia in the right hemisphere was extracted using the visualization method, followed by pretreatments including gradient dehydrating, gelatin-embedding and setting of calibration points. And then the tissue blocks was cryosectioned into 60-μm-thick coronal sections and the sectional images were captured simultaneously by a digital camera at a fixed position. Two series of sections (one section out of ten) were Nissl-stained with Toluidine blue and immunostained with the calbindin D-28K, respectively. Stained sections were digitized by a high resolution scanner. After alignment and registration, contours of nuclei and different nucleic function divisions in the digital images of stained sections were identified, and then were segmented and labeled using software exploited by ourselves. Datasets of one set of registrated serial sectional images and two sets of registrated histochemically stained images in basal ganglia area were obtained, which provide a histological reference for the neurosurgery and diagnostic imaging. a systematic method of cutting, slicing, staining, data acquisition and image registration of large tissue blocks was established, providing a reference for histological data acquisition on the digital human. Anat Rec, 300:1011-1021, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Luoyingzi Xie
- Department of Anatomy, Third Military Medical University, Chongqing, 400038, China
| | - Jingjing Rong
- Department of Anatomy, Third Military Medical University, Chongqing, 400038, China
| | - Qiyu Li
- Department of Anatomy, Third Military Medical University, Chongqing, 400038, China
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Højlund A, Petersen MV, Sridharan KS, Østergaard K. Worsening of Verbal Fluency After Deep Brain Stimulation in Parkinson's Disease: A Focused Review. Comput Struct Biotechnol J 2016; 15:68-74. [PMID: 27994799 PMCID: PMC5155048 DOI: 10.1016/j.csbj.2016.11.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/16/2016] [Accepted: 11/24/2016] [Indexed: 11/28/2022] Open
Abstract
Worsening of verbal fluency after treatment with deep brain stimulation in Parkinson's disease patients is one of the most often reported cognitive adverse effect. The underlying mechanisms of this decline are not well understood. The present focused review assesses the evidence for the reliability of the often-reported decline of verbal fluency, as well as the evidence for the suggested mechanisms including disease progression, reduced medication levels, electrode positions, and stimulation effect vs. surgical effects. Finally, we highlight the need for more systematic investigations of the large degree of heterogeneity in the prevalence of verbal fluency worsening after DBS, as well as provide suggestions for future research.
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Affiliation(s)
- Andreas Højlund
- Center of Functionally Integrative Neuroscience (CFIN), Dept. of Clinical Medicine, Aarhus University, Denmark
| | - Mikkel V Petersen
- Center of Functionally Integrative Neuroscience (CFIN), Dept. of Clinical Medicine, Aarhus University, Denmark
| | - Kousik Sarathy Sridharan
- Center of Functionally Integrative Neuroscience (CFIN), Dept. of Clinical Medicine, Aarhus University, Denmark
| | - Karen Østergaard
- Center of Functionally Integrative Neuroscience (CFIN), Dept. of Clinical Medicine, Aarhus University, Denmark
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Garcia-Garcia D, Guridi J, Toledo JB, Alegre M, Obeso JA, Rodríguez-Oroz MC. Stimulation sites in the subthalamic nucleus and clinical improvement in Parkinson's disease: a new approach for active contact localization. J Neurosurg 2016; 125:1068-1079. [DOI: 10.3171/2015.9.jns15868] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is widely used in patients with Parkinson's disease (PD). However, which target area of this region results in the highest antiparkinsonian efficacy is still a matter of debate. The aim of this study was to develop a more accurate methodology to locate the electrodes and the contacts used for chronic stimulation (active contacts) in the subthalamic region, and to determine the position at which stimulation conveys the greatest clinical benefit.
METHODS
The study group comprised 40 patients with PD in whom bilateral DBS electrodes had been implanted in the STN. Based on the Morel atlas, the authors created an adaptable 3D atlas that takes into account individual anatomical variability and divides the STN into functional territories. The locations of the electrodes and active contacts were obtained from an accurate volumetric assessment of the artifact using preoperative and postoperative MR images. Active contacts were positioned in the 3D atlas using stereotactic coordinates and a new volumetric method based on an ellipsoid representation created from all voxels that belong to a set of contacts. The antiparkinsonian benefit of the stimulation was evaluated by the reduction in the Unified Parkinson's Disease Rating Scale Part III (UPDRS-III) score and in the levodopa equivalent daily dose (LEDD) at 6 months. A homogeneous group classification for contact position and the respective clinical improvement was applied using a hierarchical clustering method.
RESULTS
Subthalamic stimulation induced a significant reduction of 58.0% ± 16.5% in the UPDRS-III score (p < 0.001) and 64.9% ± 21.0% in the LEDD (p < 0.001). The greatest reductions in the total and contralateral UPDRS-III scores (64% and 76%, respectively) and in the LEDD (73%) were obtained when the active contacts were placed approximately 12 mm lateral to the midline, with no influence of the position being observed in the anteroposterior and dorsoventral axes. In contrast, contacts located about 10 mm from the midline only reduced the global and contralateral UPDRS-III scores by 47% and 41%, respectively, and the LEDD by 33%. Using the ellipsoid method of location, active contacts with the highest benefit were positioned in the rostral and most lateral portion of the STN and at the interface between this subthalamic region, the zona incerta, and the thalamic fasciculus. Contacts placed in the most medial regions of the motor STN area provided the lowest clinical efficacy.
CONCLUSIONS
The authors report an accurate new methodology to assess the position of electrodes and contacts used for chronic subthalamic stimulation. Using this approach, the highest antiparkinsonian benefit is achieved when active contacts are located within the rostral and the most lateral parts of the motor region of the STN and at the interface of this region and adjacent areas (zona incerta and thalamic fasciculus).
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Affiliation(s)
- David Garcia-Garcia
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
| | - Jorge Guridi
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
| | - Jon B. Toledo
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
| | - Manuel Alegre
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
| | - José A. Obeso
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
| | - María C. Rodríguez-Oroz
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
- 3Neuroscience Unit, BioDonostia Research Institute, University Hospital Donostia, Basque Center on Cognition, Brain and Language (BCBL), San Sebastián; Ikerbasque, Basque Foundation for Science, Bilbao, Spain
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26
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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: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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27
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Sharim J, Yazdi D, Baohan A, Behnke E, Pouratian N. Modeling Laterality of the Globus Pallidus Internus in Patients With Parkinson's Disease. Neuromodulation 2016; 20:238-242. [PMID: 27465487 DOI: 10.1111/ner.12480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/03/2016] [Accepted: 06/26/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Neurosurgical interventions such as deep brain stimulation surgery of the globus pallidus internus (GPi) play an important role in the treatment of medically refractory Parkinson's disease (PD), and require high targeting accuracy. Variability in the laterality of the GPi across patients with PD has not been well characterized. The aim of this report is to identify factors that may contribute to differences in position of the motor region of GPi. MATERIALS AND METHODS The charts and operative reports of 101 PD patients following deep brain stimulation surgery (70 males, aged 11-78 years) representing 201 GPi were retrospectively reviewed. Data extracted for each subject include age, gender, anterior and posterior commissures (AC-PC) distance, and third ventricular width. Multiple linear regression, stepwise regression, and relative importance of regressors analysis were performed to assess the predictive ability of these variables on GPi laterality. RESULTS Multiple linear regression for target vs. third ventricular width, gender, AC-PC distance, and age were significant for normalized linear regression coefficients of 0.333 (p < 0.0001), 0.206 (p = 0.00219), 0.168 (p = 0.0119), and 0.159 (p = 0.0136), respectively. Third ventricular width, gender, AC-PC distance, and age each account for 44.06% (21.38-65.69%, 95% CI), 20.82% (10.51-35.88%), 21.46% (8.28-37.05%), and 13.66% (2.62-28.64%) of the R2 value, respectively. Effect size calculation was significant for a change in the GPi laterality of 0.19 mm per mm of ventricular width, 0.11 mm per mm of AC-PC distance, 0.017 mm per year in age, and 0.54 mm increase for male gender. CONCLUSION This variability highlights the limitations of indirect targeting alone, and argues for the continued use of MRI as well as intraoperative physiological testing to account for such factors that contribute to patient-specific variability in GPi localization.
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Affiliation(s)
- Justin Sharim
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel Yazdi
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Amy Baohan
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Eric Behnke
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Department of Bioengineering, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Neuroscience Interdepartmental Program, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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28
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Ughratdar I, Samuel M, Ashkan K. Technological Advances in Deep Brain Stimulation. JOURNAL OF PARKINSONS DISEASE 2016; 5:483-96. [PMID: 26406128 DOI: 10.3233/jpd-150579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Functional and stereotactic neurosurgery has always been regarded as a subspecialty based on and driven by technological advances. However until recently, the fundamentals of deep brain stimulation (DBS) hardware and software design had largely remained stagnant since its inception almost three decades ago. Recent improved understanding of disease processes in movement disorders as well clinician and patient demands has resulted in new avenues of development for DBS technology. This review describes new advances both related to hardware and software for neuromodulation. New electrode designs with segmented contacts now enable sophisticated shaping and sculpting of the field of stimulation, potentially allowing multi-target stimulation and avoidance of side effects. To avoid lengthy programming sessions utilising multiple lead contacts, new user-friendly software allows for computational modelling and individualised directed programming. Therapy delivery is being improved with the next generation of smaller profile, longer-lasting, re-chargeable implantable pulse generators (IPGs). These include IPGs capable of delivering constant current stimulation or personalised closed-loop adaptive stimulation. Post-implantation Magnetic Resonance Imaging (MRI) has long been an issue which has been partially overcome with 'MRI conditional devices' and has enabled verification of DBS lead location. Surgical technique is considering a shift from frame-based to frameless stereotaxy or greater role for robot assisted implantation. The challenge for these contemporary techniques however, will be in demonstrating equivalent safety and accuracy to conventional methods. We also discuss potential future direction utilising wireless technology allowing for miniaturisation of hardware.
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29
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Pereira JLB, B A SF, Sharim J, Yazdi D, DeSalles AAF, Pouratian N. Lateralization of the Subthalamic Nucleus with Age in Parkinson's Disease. ACTA ACUST UNITED AC 2016; 6:83-88. [PMID: 26900546 DOI: 10.1016/j.baga.2016.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Age-related changes in subthalamic nucleus (STN) position have not been well characterized in patients with Parkinson's disease (PD). We report a systematic retrospective analysis of age-related changes in radiographic and final deep brain stimulator (DBS) STN coordinates in PD patients. The charts of 134 PD patients (97 males, 28-84 years) representing 255 STN were reviewed. Multiple linear regression, stepwise regression, and relative importance of regressors analysis was performed to determine the significance of the relationship between STN position and age. Across all subjects, both radiographic STN localization and final DBS position within the STN showed a lateralization of the STN target with age (R2=0.1096,p=6.9×10-8 and R2=0.0433,p=8.7×10-4, respectively). Lateralization with age was observed regardless of MR field strength (1.5T and 3.0T) (R2=0.0946,p=7.6×10-6 and R2=0.2687,p=9.2×10-5, respectively). No other consistent or clinically significant age-related changes were identified. Multiple linear regression revealed that the third ventricle width and age are statistically significant predictors of radiographic STN lateralization (R2 = 0.2404, p = 1.51×10-5 and p = .00784 respectively). Step-wise regression demonstrated that age is a non-redundant predictor of STN lateralization relative to third ventricle width. Similar to healthy controls, STN position appears to shift laterally with age in PD. This highlights limitations of indirect targeting and atlas-based stereotactic surgery and argues for reliance on patient specific anatomy since factors such as age and 3rd ventricular width can contribute to patient-specific variability in STN localization.
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Affiliation(s)
- Julio L B Pereira
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, USA
| | - Sydney Furie B A
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, USA
| | - Justin Sharim
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, USA
| | - Daniel Yazdi
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, USA
| | - Antonio A F DeSalles
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, USA; Department of Bioengineering, David Geffen School of Medicine, University of California Los Angeles, USA; Neuroscience Interdepartmental Program, David Geffen School of Medicine, University of California Los Angeles, USA; Brain Research Institute, David Geffen School of Medicine, University of California Los Angeles, USA
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30
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Senova S, Hosomi K, Gurruchaga JM, Gouello G, Ouerchefani N, Beaugendre Y, Lepetit H, Lefaucheur JP, Badin RA, Dauguet J, Jan C, Hantraye P, Brugières P, Palfi S. Three-dimensional SPACE fluid-attenuated inversion recovery at 3 T to improve subthalamic nucleus lead placement for deep brain stimulation in Parkinson's disease: from preclinical to clinical studies. J Neurosurg 2016; 125:472-80. [PMID: 26745490 DOI: 10.3171/2015.7.jns15379] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established therapy for motor symptoms in patients with pharmacoresistant Parkinson's disease (PD). However, the procedure, which requires multimodal perioperative exploration such as imaging, electrophysiology, or clinical examination during macrostimulation to secure lead positioning, remains challenging because the STN cannot be reliably visualized using the gold standard, T2-weighted imaging (T2WI) at 1.5 T. Thus, there is a need to improve imaging tools to better visualize the STN, optimize DBS lead implantation, and enlarge DBS diffusion. METHODS Gradient-echo sequences such as those used in T2WI suffer from higher distortions at higher magnetic fields than spin-echo sequences. First, a spin-echo 3D SPACE (sampling perfection with application-optimized contrasts using different flip angle evolutions) FLAIR sequence at 3 T was designed, validated histologically in 2 nonhuman primates, and applied to 10 patients with PD; their data were clinically compared in a double-blind manner with those of a control group of 10 other patients with PD in whom STN targeting was performed using T2WI. RESULTS Overlap between the nonhuman primate STNs segmented on 3D-histological and on 3D-SPACE-FLAIR volumes was high for the 3 most anterior quarters (mean [± SD] Dice scores 0.73 ± 0.11, 0.74 ± 0.06, and 0.60 ± 0.09). STN limits determined by the 3D-SPACE-FLAIR sequence were more consistent with electrophysiological edges than those determined by T2WI (0.9 vs 1.4 mm, respectively). The imaging contrast of the STN on the 3D-SPACE-FLAIR sequence was 4 times higher (p < 0.05). Improvement in the Unified Parkinson's Disease Rating Scale Part III score (off medication, on stimulation) 12 months after the operation was higher for patients who underwent 3D-SPACE-FLAIR-guided implantation than for those in whom T2WI was used (62.2% vs 43.6%, respectively; p < 0.05). The total electrical energy delivered decreased by 36.3% with the 3D-SPACE-FLAIR sequence (p < 0.05). CONCLUSIONS 3D-SPACE-FLAIR sequences at 3 T improved STN lead placement under stereotactic conditions, improved the clinical outcome of patients with PD, and increased the benefit/risk ratio of STN-DBS surgery.
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Affiliation(s)
- Suhan Senova
- Service de Neurochirurgie.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil
| | - Koichi Hosomi
- Service de Neurochirurgie.,Faculté de Médecine, Université Paris Est, Créteil;,DSV/I2BM/MIRCen/Laboratory of Neurodegenerative Diseases, CNRS, Commissariat à l'Energie Atomique, Fontenay-aux-Roses; and
| | - Jean-Marc Gurruchaga
- Service de Neurochirurgie.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil
| | - Gaëtane Gouello
- Service de Neurochirurgie.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil
| | - Naoufel Ouerchefani
- Service de Neurochirurgie.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil
| | | | - Hélène Lepetit
- Service de Neurochirurgie.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil
| | - Jean-Pascal Lefaucheur
- Service des Explorations Fonctionnelles, Assistance Publique des Hopitaux de Paris, Hôpital H. Mondor, DHU PePsy;,Faculté de Médecine, Université Paris Est, Créteil
| | - Romina Aron Badin
- DSV/I2BM/MIRCen/Laboratory of Neurodegenerative Diseases, CNRS, Commissariat à l'Energie Atomique, Fontenay-aux-Roses; and
| | - Julien Dauguet
- DSV/I2BM/MIRCen/Laboratory of Neurodegenerative Diseases, CNRS, Commissariat à l'Energie Atomique, Fontenay-aux-Roses; and
| | - Caroline Jan
- DSV/I2BM/MIRCen/Laboratory of Neurodegenerative Diseases, CNRS, Commissariat à l'Energie Atomique, Fontenay-aux-Roses; and
| | - Philippe Hantraye
- DSV/I2BM/MIRCen/Laboratory of Neurodegenerative Diseases, CNRS, Commissariat à l'Energie Atomique, Fontenay-aux-Roses; and
| | - Pierre Brugières
- Service de Neuroradiologie, and.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil;,DSV/I2BM/Neurospin/UNIACT, Commissariat à l'Energie Atomique, Saclay, France
| | - Stéphane Palfi
- Service de Neurochirurgie.,Inserm U955 Team 14;,Faculté de Médecine, Université Paris Est, Créteil
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Schönecker T, Gruber D, Kivi A, Müller B, Lobsien E, Schneider GH, Kühn AA, Hoffmann KT, Kupsch AR. Postoperative MRI localisation of electrodes and clinical efficacy of pallidal deep brain stimulation in cervical dystonia. J Neurol Neurosurg Psychiatry 2015; 86:833-9. [PMID: 25253870 DOI: 10.1136/jnnp-2014-308159] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/28/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Pallidal deep brain stimulation (DBS) has been shown to be effective in cervical dystonia (CD) with an improvement of about 50-60% in the Toronto Western Spasmodic Torticollis Rating (TWSTR) Scale. However, predictive factors for the efficacy of DBS in CD are missing with the anatomical location of the electrodes being one of the most important potential predictive factors. METHODS In the present blinded observational study we correlated the anatomical localisation of DBS contacts with the relative clinical improvement (CI %) in the TWSTR as achieved by DBS at different pallidal contacts in 20 patients with CD. Localisations of DBS contacts were derived from postoperative MRI-data following anatomical normalisation into the standard Montreal Neurological Institute stereotactic space. The CIs following 76 bilateral test stimulations of 24 h were mapped to stereotactic coordinates of the corresponding bilateral 152 active contacts and were allocated to low CI (<30%; n=74), intermediate CI (≥30%; <60%; n=52) or high CI (≥60%; n=26). RESULTS Euclidean distances between contacts and the centroid differed between the three clusters (p<0.001) indicating different anatomical variances between clusters. The Euclidean distances between contacts and the centroid of the cluster with high CIs correlated with the individual level of CIs (r=-0.61; p<0.0001). This relationship was best fitted with an exponential regression curve (r(2)=0.41). DISCUSSION Our data show that the clinical effect of pallidal DBS on CD displays an exponential decay over anatomical distance from an optimised target localisation within a subregion of the internal pallidum. The results will allow a comparison of future DBS studies with postoperative MRI by verifying optimised (for instance pallidal) targeting in DBS-treated patients.
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Affiliation(s)
- Thomas Schönecker
- Department of Neurology, Charité, University Medicine Berlin, Germany Klinikum Bremeraven, Germany
| | - Doreen Gruber
- Department of Neurology, Charité, University Medicine Berlin, Germany Movement Disorder Clinic Beelitz Heilstätten, Germany
| | - Anatol Kivi
- Department of Neurology, Charité, University Medicine Berlin, Germany Department of Neurology, Vivantes Clinic Berlin Spandau, Germany
| | - Bianca Müller
- Department of Neurology, Charité, University Medicine Berlin, Germany Department of Neurology, Vivantes Clinic Berlin Spandau, Germany
| | - Elmar Lobsien
- Department of Neurology, Charité, University Medicine Berlin, Germany Department of Neurology, Helios Clinic, Erfurt, Germany
| | | | - Andrea A Kühn
- Department of Neurology, Charité, University Medicine Berlin, Germany
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, University of Leipzig, Germany Department of Neuroradiology, Charité, University Medicine, Berlin, Germany
| | - Andreas R Kupsch
- Department of Neurology, Charité, University Medicine Berlin, Germany Departments of Neurology and Stereotactic Neurosurgery, Magdeburg, Germany
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32
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Kim J, Lenglet C, Duchin Y, Sapiro G, Harel N. Semiautomatic segmentation of brain subcortical structures from high-field MRI. IEEE J Biomed Health Inform 2015; 18:1678-95. [PMID: 25192576 DOI: 10.1109/jbhi.2013.2292858] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Volumetric segmentation of subcortical structures, such as the basal ganglia and thalamus, is necessary for noninvasive diagnosis and neurosurgery planning. This is a challenging problem due in part to limited boundary information between structures, similar intensity profiles across the different structures, and low contrast data. This paper presents a semiautomatic segmentation system exploiting the superior image quality of ultrahigh field (7 T) MRI. The proposed approach utilizes the complementary edge information in the multiple structural MRI modalities. It combines optimally selected two modalities from susceptibility-weighted, T2-weighted, and diffusion MRI, and introduces a tailored new edge indicator function. In addition to this, we employ prior shape and configuration knowledge of the subcortical structures in order to guide the evolution of geometric active surfaces. Neighboring structures are segmented iteratively, constraining oversegmentation at their borders with a nonoverlapping penalty. Several experiments with data acquired on a 7 T MRI scanner demonstrate the feasibility and power of the approach for the segmentation of basal ganglia components critical for neurosurgery applications such as deep brain stimulation surgery.
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Houshmand L, Cummings KS, Chou KL, Patil PG. Evaluating indirect subthalamic nucleus targeting with validated 3-tesla magnetic resonance imaging. Stereotact Funct Neurosurg 2014; 92:337-45. [PMID: 25358805 DOI: 10.1159/000366286] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 08/04/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/OBJECTIVES Indirect targeting of the subthalamic nucleus (STN) is commonly utilized at deep brain stimulation (DBS) centers around the world. The superiority of either midcommissural point (MCP)-based or red nucleus (RN)-based indirect targeting remains to be established. METHODS The location of the STN was determined and statistically compared to MCP- and RN-based predictions in 58 STN DBS patients, using a validated 3-tesla MRI protocol. The influence of additional neuroanatomical parameters on STN midpoint location was evaluated. Linear regression analysis was utilized to produce an optimized MCP/RN targeting model. Targeting coordinates at 1.5 T were compared to results at 3 T. RESULTS Accuracy and precision for RN-based targeting was superior to MCP-based targeting to predict STN midpoint location for each coordinate dimension (p < 0.01 and p < 0.05, respectively). RN-based targeting was statistically equivalent to an optimized regression-based targeting strategy incorporating multiple neuroanatomical parameters, including third-ventricle width and overall brain size. RN-based targeting at 1.5 T yielded equivalent coordinates to targeting at 3 T. CONCLUSIONS RN-based targeting is statistically superior to MCP-based STN targeting and accommodates broad variations in neuroanatomical parameters. Neurosurgeons utilizing indirect targeting of the STN may consider favoring RN-based over MCP-based indirect targeting methods.
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Affiliation(s)
- Layla Houshmand
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, Mich., USA
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Sarkar SN, Sarkar PR, Papavassiliou E. Subthalamic Nuclear Tissue Contrast in Inversion Recovery MRI Decreases with Age in Medically Refractory Parkinson's Disease. J Neuroimaging 2014; 25:303-306. [DOI: 10.1111/jon.12111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/30/2013] [Accepted: 12/30/2013] [Indexed: 12/01/2022] Open
Affiliation(s)
- Subhendra N. Sarkar
- Department of Radiology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA 02215
| | - Pooja R. Sarkar
- School of Medicine; University of Texas Health Science Center; San Antonio TX 78229
| | - Efstathios Papavassiliou
- Division of Neurosurgery; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA 02215
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Xiao Y, Jannin P, D'Albis T, Guizard N, Haegelen C, Lalys F, Vérin M, Collins DL. Investigation of morphometric variability of subthalamic nucleus, red nucleus, and substantia nigra in advanced Parkinson's disease patients using automatic segmentation and PCA-based analysis. Hum Brain Mapp 2014; 35:4330-44. [PMID: 24652699 DOI: 10.1002/hbm.22478] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 01/07/2014] [Accepted: 01/16/2014] [Indexed: 01/02/2023] Open
Abstract
Subthalamic nucleus (STN) deep brain stimulation (DBS) is an effective surgical therapy to treat Parkinson's disease (PD). Conventional methods employ standard atlas coordinates to target the STN, which, along with the adjacent red nucleus (RN) and substantia nigra (SN), are not well visualized on conventional T1w MRIs. However, the positions and sizes of the nuclei may be more variable than the standard atlas, thus making the pre-surgical plans inaccurate. We investigated the morphometric variability of the STN, RN and SN by using label-fusion segmentation results from 3T high resolution T2w MRIs of 33 advanced PD patients. In addition to comparing the size and position measurements of the cohort to the Talairach atlas, principal component analysis (PCA) was performed to acquire more intuitive and detailed perspectives of the measured variability. Lastly, the potential correlation between the variability shown by PCA results and the clinical scores was explored.
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Affiliation(s)
- Yiming Xiao
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, Canada
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Anatomy of the human subthalamic nucleus: a combined morphometric study. ANATOMY RESEARCH INTERNATIONAL 2013; 2013:319710. [PMID: 24416591 PMCID: PMC3876692 DOI: 10.1155/2013/319710] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 10/24/2013] [Accepted: 10/30/2013] [Indexed: 11/17/2022]
Abstract
Purpose. Our purpose was to provide a combined clinically oriented study focused on the detailed anatomy of the human STN, with great respect to its targeting. Methods. For our imaging study, we used cerebral magnetic resonance images (MRIs) from 26 neurosurgical patients and for our anatomic study 32 cerebral hemispheres from 18 normal brains from cadaver donors. We measured and analyzed the STN dimensions (based on its stereotactic coordinates). Results. At stereotactic level Z = −4, the STN length was 7.7 mm on MRIs and 8.1 mm in anatomic specimens. Its width was 6 mm on MRIs and 6.3 mm in anatomic specimens. The STN was averagely visible in 3.2 transverse MRI slices and its maximum dimension was 8.5 mm. The intercommissural distance was 26.3 mm on MRIs and 27.3 mm in anatomic specimens. We found statistically significant difference of the STN width and length between individuals <60 and ≥60 years old. Conclusion. The identification of the STN limits was easier in anatomic specimens than on MRIs and easier on T2 compared to T1-weighted MRIs sections. STN dimensions appear slightly smaller on MRIs. Younger people have wider and longer STN.
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Abstract
Deep brain stimulation an effective treatment of many neurologic conditions such as Parkinson disease, essential tremor, dystonia, and obsessive-compulsive disorder. Structural and functional neuroimaging studies provide the opportunity to visualize the dysfunctional nodes and networks underlying neurologic and psychiatric disease, and to thereby realize new targets for neuromodulation as well as personalize current therapy. This article reviews contemporary advances in neuroimaging in the basic sciences and how they can be applied to redirect and propel functional neurosurgery toward a goal of functional localization of targets with individualized maps and identification of novel targets for other neuropsychiatric diseases.
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Höflich A, Savli M, Comasco E, Moser U, Novak K, Kasper S, Lanzenberger R. Neuropsychiatric deep brain stimulation for translational neuroimaging. Neuroimage 2013; 79:30-41. [DOI: 10.1016/j.neuroimage.2013.04.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 04/13/2013] [Accepted: 04/16/2013] [Indexed: 10/26/2022] Open
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Camlidag I, Kocabicak E, Sahin B, Jahanshahi A, Incesu L, Aygun D, Yildiz O, Temel Y, Belet U. Volumetric analysis of the subthalamic and red nuclei based on magnetic resonance imaging in patients with Parkinson's disease. Int J Neurosci 2013; 124:291-5. [PMID: 24020352 DOI: 10.3109/00207454.2013.843091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Parkinson's disease (PD) is associated with degeneration of the dopaminergic neurons in the substantia nigra. The subthalamic nucleus (STN) plays a pivotal role in the pathogenesis. However, there is not much known about the morphological changes in the STN. The red nucleus (RN) has many connections with the motor coordinating pathways although it is not primarily involved in the pathogenesis. In this study we aimed to compare the volumes of the STN and RN measured by magnetic resonance imaging in PD patients and controls to investigate how these structures are affected at the morphological level. Twenty patients with PD and twenty age/sex matched controls were enrolled in this study. Severity score was determined by Hoehn & Yahr staging: 6 at stage II and 14 at stage III in med-off state. Imaging was performed by a 1.5 Tesla (T) MR scanner. Measurements of total brain and normalized STN and RN volumes were performed by manual planimetry using Image J software. No statistically significant differences were observed between two groups based on age or gender and disease stage and nuclei volumes. The total estimated brain volumes were not different between PD patients and controls. However, normalized volumes of the STN and RN were 14% and 16% larger, respectively, in PD patients compared to the controls (p < 0.05). Our findings suggest that the volumes of the STN and RN are increased in patients with PD. These changes possibly reflect the altered metabolic activity of these regions demonstrated by neurophysiological studies.
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Affiliation(s)
- Ilkay Camlidag
- 1Department of Radiology, Ondokuz Mayis University , Samsun , Turkey
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Sarnthein J, Péus D, Baumann-Vogel H, Baumann CR, Sürücü O. Stimulation sites in the subthalamic nucleus projected onto a mean 3-D atlas of the thalamus and basal ganglia. Acta Neurochir (Wien) 2013; 155:1655-60. [PMID: 23728503 DOI: 10.1007/s00701-013-1780-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 05/16/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients with severe forms of Parkinson's disease (PD), deep brain stimulation (DBS) commonly targets the subthalamic nucleus (STN). Recently, the mean 3-D Morel-Atlas of the basal ganglia and the thalamus was introduced. It combines information contained in histological data from ten post-mortem brains. We were interested whether the Morel-Atlas is applicable for the visualization of stimulation sites. METHODS In a consecutive PD patient series, we documented preoperative MRI planning, intraoperative target adjustment based on electrophysiological and neurological testing, and perioperative CT target reconstruction. The localization of the DBS electrodes and the optimal stimulation sites were projected onto the Morel-Atlas. RESULTS We included 20 patients (median age 62 years). The active contact had mean coordinates Xlat = ±12.1 mm, Yap = -1.8 mm, Zvert = -3.2 mm. There was a significant difference between the initially planned site and the coordinates of the postoperative active contact site (median 2.2 mm). The stimulation site was, on average, more anterior and more dorsal. The electrode contact used for optimal stimulation was found within the STN of the atlas in 38/40 (95 %) of implantations. CONCLUSIONS The cluster of stimulation sites in individual patients-as deduced from preoperative MR, intraoperative electrophysiology and neurological testing-showed a high degree of congruence with the atlas. The mean 3D Morel Atlas is thus a useful tool for postoperative target visualization. This represents the first clinical evaluation of the recently created atlas.
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Affiliation(s)
- Johannes Sarnthein
- Klinik für Neurochirurgie, UniversitätsSpital Zürich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland.
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Chrastina J, Novák Z, Baláž M, Říha I, Bočková M, Rektor I. The role of brain shift, patient age, and Parkinson's disease duration in the difference between anatomical and electrophysiological targets for subthalamic stimulation. Br J Neurosurg 2013; 27:676-82. [DOI: 10.3109/02688697.2013.771726] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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A new atlas localization approach for subthalamic nucleus utilizing Chinese visible human head datasets. PLoS One 2013; 8:e57264. [PMID: 23460836 PMCID: PMC3584111 DOI: 10.1371/journal.pone.0057264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To study the possibility of Chinese visible human (CVH) head datasets as brain atlas for locating the subthalamic nucleus (STN) before deep brain stimulation (DBS) surgery. METHODS Optimal head axial and coronal 3.0T, T2-weighted magnetic resonance images (MRI) of 30 patients were obtained. Cross-sectional head images of four CVH head datasets were chosen to establish an average CVH model. All MRI sequences were registered to the CVH model via fiducials in X-, Y-, and Z-direction, respectively, within the same stereotactic space. The correlations between red nucleus (RN) and fiducials, the accuracy of MRI-to-CVH registration, and the coordinate value differences of RN gravity center between MRI and CVH were tested. RESULTS The mean gravity center coordinate values and ranges of STN in CVH were measured; The X coordinate value of RN positively correlates with the most anterior point of putamen(PU-A), the lateral edges of putamens (PU-L), and width of the third ventricle, negatively correlated with the patients' age; The minimal mean errors were when no fiducials were used when locating RN between the MRI and the CVH average model; There were no significant differences of RN in X- and Y-direction between MRI sequences and CVH. CONCLUSION CVH head datasets can be used as brain atlas for Chinese STN localization. Moreover, average coordinate values of the gravity center and the ranges of STN in CVH can be considered as references for locating STN.
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Kerl HU, Gerigk L, Brockmann MA, Huck S, Al-Zghloul M, Groden C, Hauser T, Nagel AM, Nölte IS. Imaging for deep brain stimulation: The zona incerta at 7 Tesla. World J Radiol 2013; 5:5-16. [PMID: 23494089 PMCID: PMC3596566 DOI: 10.4329/wjr.v5.i1.5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 10/24/2012] [Accepted: 01/21/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate different promising magnetic resonance imaging (MRI) methods at 7.0 Tesla (T) for the pre-stereotactic visualization of the zona incerta (ZI).
METHODS: Two neuroradiologists qualitatively and quantitatively examined T2-turbo spin-echo (T2-TSE), T1-weighted gradient-echo, as well as FLASH2D-T2Star and susceptibility-weighted imaging (SWI) for the visualization of the ZI at 7.0 T MRI. Delineation and image quality for the ZI were independently examined using a 6-scale grading system. Inter-rater reliability using Cohen’s kappa coefficient (κ) were assessed. Contrast-to-noise ratios (CNR), and signal-to-noise ratios (SNR) for the ZI were calculated for all sequences. Differences in delineation, SNR, and CNR between the sequences were statistically assessed using a paired t-test. For the anatomic validation the coronal FLASH2D-T2Star images were co-registered with a stereotactic atlas (Schaltenbrand-Wahren).
RESULTS: The rostral part of the ZI (rZI) could easily be identified and was best and reliably visualized in the coronal FLASH2D-T2Star images. The caudal part was not definable in any of the sequences. No major artifacts in the rZI were observed in any of the scans. FLASH2D-T2Star and SWI imaging offered significant higher CNR values for the rZI compared to T2-TSE images (P > 0.05). The co-registration of the coronal FLASH2D-T2Star images with the stereotactic atlas schema (Schaltenbrand-Wahren) confirmed the correct localization of the ZI in all cases.
CONCLUSION: FLASH2D-T2Star imaging (particularly coronal view) provides the reliable and currently optimal visualization of the rZI at 7.0 T. These results can facilitate a better and more precise targeting of the caudal part of the ZI than ever before.
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Kerl HU, Gerigk L, Pechlivanis I, Al-Zghloul M, Groden C, Nölte IS. The subthalamic nucleus at 7.0 Tesla: evaluation of sequence and orientation for deep-brain stimulation. Acta Neurochir (Wien) 2012; 154:2051-62. [PMID: 22930282 DOI: 10.1007/s00701-012-1476-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 08/05/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Deep-brain stimulation (DBS) of the subthalamic nucleus (STN) is an accepted neurosurgical technique for the treatment of medication-resistant Parkinson's disease and other neurological disorders. The accurate targeting of the STN is facilitated by precise and reliable identification in pre-stereotactic magnetic resonance imaging (MRI). The aim of the study was to compare and evaluate different promising MRI methods at 7.0 T for the pre-stereotactic visualisation of the STN METHODS: MRI (T2-turbo spin-echo [TSE], T1-gradient echo [GRE], fast low-angle shot [FLASH] two-dimensional [2D] T2* and susceptibility-weighted imaging [SWI]) was performed in nine healthy volunteers. Delineation and image quality for the STN were independently evaluated by two neuroradiologists using a six-point grading system. Inter-rater reliability, contrast-to-noise ratios (CNRs) and signal-to-noise ratios (SNRs) for the STN were calculated. For the anatomical validation, the coronal FLASH 2D T2* images were co-registered with a stereotactic atlas (Schaltenbrand-Wahren). RESULTS The STN was clearly and reliably visualised in FLASH 2D T2* imaging (particularly coronal view), with a sharp delineation between the STN, the substantia nigra and the zona incerta. No major artefacts in the STN were observed in any of the sequences. FLASH 2D T2* and SWI images offered significantly higher CNR for the STN compared with T2-TSE. The co-registration of the coronal FLASH 2D T2* images with the stereotactic atlas affirmed the correct localisation of the STN in all cases. CONCLUSION The STN is best and reliably visualised in FLASH 2D T2* imaging (particularly coronal orientation) at 7.0-T MRI.
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Affiliation(s)
- Hans U Kerl
- Department of Neuroradiology, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Shamir RR, Zaidel A, Joskowicz L, Bergman H, Israel Z. Microelectrode recording duration and spatial density constraints for automatic targeting of the subthalamic nucleus. Stereotact Funct Neurosurg 2012; 90:325-34. [PMID: 22854414 DOI: 10.1159/000338252] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 02/28/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Accurate detection of the boundaries of the subthalamic nucleus (STN) in deep brain stimulation (DBS) surgery using microelectrode recording (MER) is considered to refine localization and may therefore improve clinical outcome. However, MER tends to extend operation time and its cost-utility balance has been debated. OBJECTIVES To quantify the tradeoff between accuracy of STN localization and the spatial and temporal parameters of MER that effect the operation time using an automated detection method. METHODS We retrospectively estimated the accuracy of STN detection on data from 100 microelectrode trajectories. Our dense (average step = 0.12 mm) and long (average duration = 22.5 s) MER data was downsampled in the spatial and temporal domains. Then, the STN borders were detected automatically on both the downsampled and original data and compared to each other. RESULTS With a recording duration of 16 s, average accuracy for detecting STN entry ranged from 0.06 mm for a 0.1-mm step to 0.51 mm for a 1.0-mm step. Smaller effects were found along the temporal axis. For example, a 0.1-mm recording step yielded an STN entry average accuracy ranging from 0.06 mm for a 16-second recording duration to 0.16 mm for 0.1 s. CONCLUSIONS STN entry detection error was about half of the step size. Sampling duration of STN activity can be minimized to 1 s/record without compromising accuracy. We conclude that bilateral DBS surgery time utilizing MER may be significantly shortened without compromising targeting accuracy.
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Affiliation(s)
- Reuben R Shamir
- Department of Medical Neurobiology (Physiology), Institute of Medical Research, Israel-Canada, The Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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Contarino MF, Bour LJ, Bot M, van den Munckhof P, Speelman JD, Schuurman PR, de Bie RM. Tremor-specific neuronal oscillation pattern in dorsal subthalamic nucleus of parkinsonian patients. Brain Stimul 2012; 5:305-314. [DOI: 10.1016/j.brs.2011.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 03/23/2011] [Accepted: 03/31/2011] [Indexed: 10/18/2022] Open
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Růžička F, Jech R, Nováková L, Urgošík D, Vymazal J, Růžička E. Weight gain is associated with medial contact site of subthalamic stimulation in Parkinson's disease. PLoS One 2012; 7:e38020. [PMID: 22666437 PMCID: PMC3364196 DOI: 10.1371/journal.pone.0038020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 05/02/2012] [Indexed: 01/28/2023] Open
Abstract
The aim of our study was to assess changes in body-weight in relation to active electrode contact position in the subthalamic nucleus. Regular body weight measurements were done in 20 patients with advanced Parkinson's disease within a period of 18 months after implantation. T1-weighted (1.5T) magnetic resonance images were used to determine electrode position in the subthalamic nucleus and the Unified Parkinson's disease rating scale (UPDRS-III) was used for motor assessment. The distance of the contacts from the wall of the third ventricle in the mediolateral direction inversely correlated with weight gain (r = −0.55, p<0.01) and with neurostimulation-related motor condition expressed as the contralateral hemi-body UPDRS-III (r = −0.42, p<0.01). Patients with at least one contact within 9.3 mm of the wall experienced significantly greater weight gain (9.4±(SD)4.4 kg, N = 11) than those with both contacts located laterally (3.9±2.7 kg, N = 9) (p<0.001). The position of the active contact is critical not only for motor outcome but is also associated with weight gain, suggesting a regional effect of subthalamic stimulation on adjacent structures involved in the central regulation of energy balance, food intake or reward.
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Affiliation(s)
- Filip Růžička
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Robert Jech
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
- * E-mail:
| | - Lucie Nováková
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Dušan Urgošík
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Josef Vymazal
- Department of Radiology, Na Homolce Hospital, Prague, Czech Republic
| | - Evžen Růžička
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
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Montgomery EB. Microelectrode targeting of the subthalamic nucleus for deep brain stimulation surgery. Mov Disord 2012; 27:1387-91. [PMID: 22508394 DOI: 10.1002/mds.25000] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 02/25/2012] [Accepted: 03/14/2012] [Indexed: 01/11/2023] Open
Abstract
Though microelectrode recordings likely increase the risks and costs of DBS, incremental improvement in accuracy may translate into improved outcomes that justify these risks and costs. Clinically based, controlled studies to resolve these issues are problematic. Until such studies are reported, physicians must rely on indirect evidence. The spatial variability of physiologically defined optimal targets, as determined by microelectrode recording (MER), necessary for targeting the STN was calculated. Study of the effectiveness of a MER algorithm was based on the number of penetrations required. The radius of the volume with a 99% chance of including the physiologically defined optimal target, based on 108 cases, was 4.5 mm. This is larger than the estimated radius of the DBS effect, which is variously estimated to be 2 to 3.9 mm. The 99% confidence radius in the plane orthogonal to the lead was 3.2 mm. In 70% of cases, the imaging-based trajectories corresponded to the physiologically defined optimal target. For the remaining 30% of cases, 70% required only a single additional MER tract. The radii of the 99% confidence volume and area may be larger than the effective radius of stimulation. Surveying within those volumes or areas is therefore necessary to assure that at least 99% of cases will cover the physiologically defined target. The MER algorithm was robust in detecting the physiologically defined optimal target. However, there are significant caveats in interpretation of the data.
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Affiliation(s)
- Erwin B Montgomery
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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Buhlmann J, Hofmann L, Tass PA, Hauptmann C. Modeling of a segmented electrode for desynchronizing deep brain stimulation. FRONTIERS IN NEUROENGINEERING 2011; 4:15. [PMID: 22163220 PMCID: PMC3233722 DOI: 10.3389/fneng.2011.00015] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 11/21/2011] [Indexed: 12/04/2022]
Abstract
Deep brain stimulation (DBS) is an effective therapy for medically refractory movement disorders like Parkinson’s disease. The electrodes, implanted in the target area within the human brain, generate an electric field which activates nerve fibers and cell bodies in the vicinity. Even though the different target nuclei display considerable differences in their anatomical structure, only few types of electrodes are currently commercially available. It is desirable to adjust the electric field and in particular the volume of tissue activated around the electrode with respect to the corresponding target nucleus in a such way that side effects can be reduced. Furthermore, a more selective and partial activation of the target structure is desirable for an optimal application of novel stimulation strategies, e.g., coordinated reset neuromodulation. Hence we designed a DBS electrode with a segmented design allowing a more selective activation of the target structure. We created a finite element model (FEM) of the electrode and analyzed the volume of tissue activated for this electrode design. The segmented electrode activated an area in a targeted manner, of which the dimension and position relative to the electrode could be controlled by adjusting the stimulation parameters for each electrode contact. According to our computational analysis, this directed stimulation might be superior with respect to the occurrence of side effects and it enables the application of coordinated reset neuromodulation under optimal conditions.
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Affiliation(s)
- J Buhlmann
- Institute of Neuroscience and Medicine - Neuromodulation, Research Center Jülich Jülich, Germany
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Holl EM, Petersen EA, Foltynie T, Martinez-Torres I, Limousin P, Hariz MI, Zrinzo L. Improving targeting in image-guided frame-based deep brain stimulation. Neurosurgery 2011; 67:437-47. [PMID: 21099570 DOI: 10.1227/neu.0b013e3181f7422a] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is commonly used in the treatment of movement disorders such as Parkinson disease (PD), dystonia, and other tremors. OBJECTIVE To examine systematic errors in image-guided DBS electrode placement and to explore a calibration strategy for stereotactic targeting. METHODS Pre- and postoperative stereotactic MR images were analyzed in 165 patients. The perpendicular error between planned target coordinates and electrode trajectory was calculated geometrically for all 312 DBS electrodes implanted. Improvement in motor unified PD rating scale III subscore was calculated for those patients with PD with at least 6 months of follow-up after bilateral subthalamic DBS. RESULTS Mean (standard deviation) scalar error of all electrodes was 1.4(0.9) mm with a significant difference between left and right hemispheres. Targeting error was significantly higher for electrodes with coronal approach angle (ARC) ≥10° (P < .001). Mean vector error was X: -0.6, Y: -0.7, and Z: -0.4 mm (medial, posterior, and superior directions, respectively). Targeting error was significantly improved by using a systematic calibration strategy based on ARC and target hemisphere (mean: 0.6 mm, P < .001) for 47 electrodes implanted in 24 patients. Retrospective theoretical calibration for all 312 electrodes would have reduced the mean (standard deviation) scalar error from 1.4(0.9) mm to 0.9(0.5) mm (36% improvement). With calibration, 97% of all electrodes would be within 2 mm of the intended target as opposed to 81% before calibration. There was no significant correlation between the degree of error and clinical outcome from bilateral subthalamic nucleus DBS (R = 0.07). CONCLUSION After calibration of a systematic targeting error an MR image-guided stereotactic approach would be expected to deliver 97% of all electrodes to within 2 mm of the intended target point with a single brain pass.
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Affiliation(s)
- Etienne M Holl
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom
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