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Samanta D, Aungaroon G, Albert GW, Karakas C, Joshi CN, Singh RK, Oluigbo C, Perry MS, Naik S, Reeders PC, Jain P, Abel TJ, Pati S, Shaikhouni A, Haneef Z. Advancing thalamic neuromodulation in epilepsy: Bridging adult data to pediatric care. Epilepsy Res 2024; 205:107407. [PMID: 38996686 DOI: 10.1016/j.eplepsyres.2024.107407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024]
Abstract
Thalamic neuromodulation has emerged as a treatment option for drug-resistant epilepsy (DRE) with widespread and/or undefined epileptogenic networks. While deep brain stimulation (DBS) and responsive neurostimulation (RNS) depth electrodes offer means for electrical stimulation of the thalamus in adult patients with DRE, the application of thalamic neuromodulation in pediatric epilepsy remains limited. To address this gap, the Neuromodulation Expert Collaborative was established within the Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Special Interest Group. In this expert review, existing evidence and recommendations for thalamic neuromodulation modalities using DBS and RNS are summarized, with a focus on the anterior (ANT), centromedian(CMN), and pulvinar nuclei of the thalamus. To-date, only DBS of the ANT is FDA approved for treatment of DRE in adult patients based on the results of the pivotal SANTE (Stimulation of the Anterior Nucleus of Thalamus for Epilepsy) study. Evidence for other thalamic neurmodulation indications and targets is less abundant. Despite the lack of evidence, positive responses to thalamic stimulation in adults with DRE have led to its off-label use in pediatric patients. Although caution is warranted due to differences between pediatric and adult epilepsy, the efficacy and safety of pediatric neuromodulation appear comparable to that in adults. Indeed, CMN stimulation is increasingly accepted for generalized and diffuse onset epilepsies, with recent completion of one randomized trial. There is also growing interest in using pulvinar stimulation for temporal plus and posterior quadrant epilepsies with one ongoing clinical trial in Europe. The future of thalamic neuromodulation holds promise for revolutionizing the treatment landscape of childhood epilepsy. Ongoing research, technological advancements, and collaborative efforts are poised to refine and improve thalamic neuromodulation strategies, ultimately enhancing the quality of life for children with DRE.
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Affiliation(s)
- Debopam Samanta
- Division of Child Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Gewalin Aungaroon
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory W Albert
- Department of Neurosurgery, University of Arkansas for Medical Sciences, USA
| | - Cemal Karakas
- Division of Pediatric Neurology, Department of Neurology, Norton Children's Hospital, University of Louisville, Louisville, KY 40202, USA
| | - Charuta N Joshi
- Division of Pediatric Neurology, Childrens Medical Center Dallas, UTSW, USA
| | - Rani K Singh
- Department of Pediatrics, Atrium Health-Levine Children's; Wake Forest University School of Medicine, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - M Scott Perry
- Jane and John Justin Institute for Mind Health, Cook Children's Medical Center, Ft Worth, TX, USA
| | - Sunil Naik
- Department of Pediatrics and Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Puck C Reeders
- Brain Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine and Department of Bioengineering, University of Pittsburgh
| | - Sandipan Pati
- The University of Texas Health Science Center at Houston, USA
| | - Ammar Shaikhouni
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Zulfi Haneef
- Neurology Care Line, VA Medical Center, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
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Möttönen T, Peltola J, Järvenpää S, Haapasalo J, Lehtimäki K. Impedance Characteristics of Stimulation Contacts in Deep Brain Stimulation of the Anterior Nucleus of the Thalamus and Its Relationship to Seizure Outcome in Patients With Refractory Epilepsy. Neuromodulation 2023; 26:1733-1741. [PMID: 35688700 DOI: 10.1016/j.neurom.2022.04.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/10/2022] [Accepted: 04/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is an emerging form of adjunctive therapy in focal refractory epilepsy. Unlike conventional DBS targets, the ANT is both encapsulated by white matter layers and located immediately adjacent to the cerebrospinal fluid (CSF) space. Owing to the location of the ANT, implantation has most commonly been performed using a transventricular trajectory. Previous studies suggest different electrical conductivity between gray matter, white matter, and CSF. OBJECTIVES In this study, we asked whether therapeutic impedance values from a fully implanted DBS device could be used to deduce the actual location of the active contact to optimize the stimulation site. Secondly, we tested whether impedance values correlate with patient outcomes. MATERIALS AND METHODS A total of 16 patients with ANT-DBS for refractory epilepsy were evaluated in this prospective study. Therapeutic impedance values were recorded on regular outpatient clinic visits. Contact locations were analyzed using delayed contrast-enhanced postoperative computed tomography-3T magnetic resonance imaging short tau inversion recovery fusion images previously shown to demonstrate anatomical details around the ANT. RESULTS Transventricularly implanted contacts immediately below the CSF surface showed overall lower and slightly decreasing impedances over time compared with higher and more stable impedances in contacts with deeper parenchymal location. Impedance values in transventricularly implanted contacts in the ANT were significantly lower than those in transventricularly implanted contacts outside the ANT or extraventricularly implanted contacts that were typically at the posterior/inferior/lateral border of the ANT. Increasing contact distance from the CSF surface was associated with a linear increase in therapeutic impedance. We also found that therapeutic impedance values were significantly lower in contacts with favorable therapy response than in nonresponding contacts. Finally, we observed a significant correlation between the left- and right-side averaged impedance and the reduction of the total number of seizures. CONCLUSIONS Valuable information can be obtained from the noninvasive measurement of therapeutic impedances. The selection of active contacts to target stimulation to the anterior nucleus may be guided by therapeutic impedance measurements to optimize outcome.
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Affiliation(s)
- Timo Möttönen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland.
| | - Jukka Peltola
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Soila Järvenpää
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Joonas Haapasalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Kai Lehtimäki
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
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Sobstyl M, Konopko M, Sienkiewicz-Jarosz H, Kurkowska-Jastrzębska I, Nagańska E, Stapińska-Syniec A, Glinka P, Rylski M. Clinical efficacy and safety of anterior thalamic deep brain stimulation for intractable drug resistant epilepsy. Epilepsy Res 2023; 195:107199. [PMID: 37531721 DOI: 10.1016/j.eplepsyres.2023.107199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/28/2023] [Accepted: 07/23/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Deep brain stimulation of the anterior nucleus of the thalamus (ANT DBS) is a neuromodulation therapy for patients with refractory focal seizures evolving into bilateral tonic-clonic seizures when pharmacotherapy as well other neuromodulation techniques including vagus nerve stimulation or responsive neurostimulation have failed. OBJECTIVE We performed a prospective single-center study investigating the clinical efficacy and exact ANT DBS lead location in patients with DRE. METHODS The primary outcome measure was the proportion of patients with more than 50 % reduction in diary-recorded seizures when compared to three preoperative months (baseline seizure frequency). The close postoperative follow-up was performed every 3 months. The seizure frequency, stimulation settings and adverse events were closely monitored during follow-up visits. We also analyzed the seizure outcome with location of ANT DBS active contacts. RESULTS Between May 2020 and October 2022, 10 adult patients with a mean age of 38.5 years (range, 30-48 years) underwent bilateral ANT DBS surgery (mean duration of DRE 28.6 years, range 16-41 years). The median seizure count in three months period preceding surgery (baseline seizure count) was 43.2 (range, 4-150). Nine patients achieved more than 50 % seizure reduction at the last follow-up (mean range 3-33 13.6 months, months). ANT DBS caused seizure reduction 3 months after procedure as well as at last follow-up by 60.4 % and 73.3 %, respectively. Due to relatively small number of studying individuals we cannot precisely locate the area within ANT associated with good clinical outcome. Patients with temporal lobe epilepsy had a remarkable reduction of seizure frequency. No patient suffered transient or permanent neurological deficits. CONCLUSIONS Clinical efficacy of ANT DBS may support more widespread utilization of this neuromodulation technique especially for seizures originating from temporal lobes.
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Affiliation(s)
- Michał Sobstyl
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland.
| | - Magdalena Konopko
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Halina Sienkiewicz-Jarosz
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Iwona Kurkowska-Jastrzębska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Ewa Nagańska
- Department of Neurology and Epileptology, Independent Public Clinical Hospital, Medical Center for Postgraduate Education, Czerniakowska 231 Street, 00-416 Warsaw, Poland
| | - Angelika Stapińska-Syniec
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Piotr Glinka
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
| | - Marcin Rylski
- Department of Radiology, Institute of Psychiatry and Neurology, Sobieskiego 9 Street, 02-957 Warsaw, Poland
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Fisher RS. Deep brain stimulation of thalamus for epilepsy. Neurobiol Dis 2023; 179:106045. [PMID: 36809846 DOI: 10.1016/j.nbd.2023.106045] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Neuromodulation (neurostimulation) is a relatively new and rapidly growing treatment for refractory epilepsy. Three varieties are approved in the US: vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS). This article reviews thalamic DBS for epilepsy. Among many thalamic sub-nuclei, DBS for epilepsy has been targeted to the anterior nucleus (ANT), centromedian nucleus (CM), dorsomedial nucleus (DM) and pulvinar (PULV). Only ANT is FDA-approved, based upon a controlled clinical trial. Bilateral stimulation of ANT reduced seizures by 40.5% at three months in the controlled phase (p = .038) and 75% by 5 years in the uncontrolled phase. Side effects related to paresthesias, acute hemorrhage, infection, occasional increased seizures, and usually transient effects on mood and memory. Efficacy was best documented for focal onset seizures in temporal or frontal lobe. CM stimulation may be useful for generalized or multifocal seizures and PULV for posterior limbic seizures. Mechanisms of DBS for epilepsy are largely unknown, but animal work points to changes in receptors, channels, neurotransmitters, synapses, network connectivity and neurogenesis. Personalization of therapies, in terms of connectivity of the seizure onset zone to the thalamic sub- nucleus and individual characteristics of the seizures, might lead to improved efficacy. Many questions remain about DBS, including the best candidates for different types of neuromodulation, the best targets, the best stimulation parameters, how to minimize side effects and how to deliver current noninvasively. Despite the questions, neuromodulation provides useful new opportunities to treat people with refractory seizures not responding to medicines and not amenable to resective surgery.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences and Neurosurgery by Courtesy, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 213 Quarry Road, Room 4865, Palo Alto, CA 94304, USA.
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O’Donnell CM, Swanson SJ, Carlson CE, Raghavan M, Pahapill PA, Anderson CT. Responsive Neurostimulation of the Anterior Thalamic Nuclei in Refractory Genetic Generalized Epilepsy: A Case Series. Brain Sci 2023; 13:brainsci13020324. [PMID: 36831867 PMCID: PMC9954640 DOI: 10.3390/brainsci13020324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023] Open
Abstract
Genetic generalized epilepsies (GGEs) are thought to represent disorders of thalamocortical networks. There are currently no well-established non-pharmacologic treatment options for patients with drug-resistant GGE. NeuroPace's Responsive Neurostimulation (RNS) System was approved by the United States Food and Drug Administration to treat focal seizures with up to two ictal foci. We report on three adults with drug-resistant GGE who were treated with thalamic RNS. Given the severity of their epilepsies and the potential ictogenic role of the thalamus in the pathophysiology of GGE, the RNS System was palliatively implanted with leads in the bilateral anterior thalamic nuclei (ANT) of these patients. The ANT was selected because it was demonstrated to be a safe target. We retrospectively evaluated metrics including seizure frequency over 18-32 months. One patient required explantation due to infection. The other two patients were clinical responders. By the end of the observation period reported here, one patient was seizure-free for over 9 months. All three self-reported an improved quality of life. The clinical response observed in these patients provides 'proof-of-principle' that GGE may be treatable with responsive thalamic stimulation. Our results support proceeding to a larger study investigating the efficacy and safety of thalamic RNS in drug-resistant GGE.
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Affiliation(s)
- Carly M. O’Donnell
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
- Correspondence:
| | - Sara J. Swanson
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Chad E. Carlson
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Manoj Raghavan
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Peter A. Pahapill
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Christopher Todd Anderson
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Deep brain stimulation of thalamic nuclei for the treatment of drug-resistant epilepsy: Are we confident with the precise surgical target? Seizure 2023; 105:22-28. [PMID: 36657225 DOI: 10.1016/j.seizure.2023.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/16/2023] Open
Abstract
Deep brain stimulation (DBS) of the thalamic nuclei for the treatment of drug-resistant epilepsy (DRE) has been investigated for decades. In recent years, DBS targeting the anterior nucleus of the thalamus (ANT) was approved by CE and FDA for the treatment of focal-onset DRE in light of the results from the multicentric randomized controlled SANTE trial. However, stereotactic targeting of thalamic nuclei is not straightforward because of the low contrast definition among thalamic nuclei on the current MRI sequences. When the FGATIR sequence is added to the preoperative MRI protocol, the mammillothalamic tract can be identified and used as a visible landmark to directly target ANT. According to the current evidence, the trans-ventricular trajectory allows the placement of stimulating contact into the nucleus more frequently than the trans-cortical trajectory. Another thalamic nucleus whose stimulation for the treatment of generalized DRE is receiving increasing attention is the centromedian nucleus (CM). CM-DBS seems to be particularly efficacious in patients suffering from Lennox-Gastault syndrome (LGS) and the recent monocentric randomized controlled ESTEL trial also described a beneficial "sweet-spot". However, CM targeting is still based on indirect stereotactic coordinates, since acquisition times and post-processing techniques of the actual MRI sequences are not applicable in clinical practice. Moreover, the results of the ESTEL trial await confirmation from similar studies accounting for epileptic syndromes other than LGS. Therefore, novel neuroimaging approaches are advisable to improve the surgical targeting of CM and potentially tailor the stimulation based on the patient's specific epileptic phenotype.
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Poulen G, Rolland A, Chan-Seng E, Sanrey E, Gélisse P, Crespel A, Coubes P. Microendoscopic transventricular deep brain stimulation of the anterior nucleus of the thalamus as a safe treatment in intractable epilepsy: A feasibility study. Rev Neurol (Paris) 2022; 178:886-895. [PMID: 36153255 DOI: 10.1016/j.neurol.2022.03.023] [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: 12/06/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is proposed in patients with severe intractable epilepsy. When used, the transventricular approach increases the risk of bleeding due the anatomy around the entry point in the thalamus. To avoid such a complication, we used a transventricular microendoscopic technique. METHODS We performed a retrospective study of nine adult patients who were surgically treated for refractory epilepsy between 2010 and 2019 by DBS of the anterior thalamic nucleus. RESULTS Endoscopy provides a direct visual control of the entry point of the lead in the thalamus through the ventricle by avoiding ependymal vessels. No hemorrhage was recorded and accuracy was systematically checked by intraoperative stereotactic MRI. We reported a responder rate improvement in 88.9% of patients at 1 year and in 87.5% at 2 years. We showed a significant decrease in global seizure count per month one year after DBS (68.1%; P=0.013) leading to an overall improvement in quality of life. No major adverse effect was recorded during the follow-up. ANT DBS showed a prominent significant effect with a decrease of the number of generalized seizures. CONCLUSION We aimed at a better ANT/lead collimation using a vertical transventricular approach under microendoscopic monitoring. This technique permitted to demonstrate the safety and the accuracy of the procedure.
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Affiliation(s)
- G Poulen
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France.
| | - A Rolland
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - E Chan-Seng
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - E Sanrey
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - P Gélisse
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - A Crespel
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - P Coubes
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
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Gummadavelli A, Englot DJ, Schwalb JM, Wu C, Gonzalez-Martinez J, Niemat J, Gerrard JL. ASSFN Position Statement on Deep Brain Stimulation for Medication-Refractory Epilepsy. Neurosurgery 2022; 90:636-641. [PMID: 35271523 PMCID: PMC9514731 DOI: 10.1227/neu.0000000000001923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
Neuromodulation has taken a foothold in the landscape of surgical treatment for medically refractory epilepsies and offers additional surgical treatment options for patients who are not candidates for resective/ablative surgery. Approximately one third of patients with epilepsy suffer with medication-refractory epilepsy. A persistent underuse of epilepsy surgery exists. Neuromodulation treatments including deep brain stimulation (DBS) expand the surgical options for patients with epilepsy and provide options for patients who are not candidates for resective surgery. DBS of the bilateral anterior nucleus of the thalamus is an Food and Drug Administration-approved, safe, and efficacious treatment option for patients with refractory focal epilepsy. The purpose of this consensus position statement is to summarize evidence, provide recommendations, and identify indications and populations for future investigation in DBS for epilepsy. The recommendations of the American Society of Functional and Stereotactic Neurosurgeons are based on several randomized and blinded clinical trials with high-quality data to support the use of DBS to the anterior nucleus of the thalamus for the treatment of refractory focal-onset seizures.
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Affiliation(s)
- Abhijeet Gummadavelli
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA;
| | - Dario J. Englot
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA;
| | - Jason M. Schwalb
- Department of Neurological Surgery, Henry Ford Health System, Detroit, Michigan, USA;
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA;
| | - Jorge Gonzalez-Martinez
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA;
| | - Joseph Niemat
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Jason L. Gerrard
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA;
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Boutet A, Loh A, Chow CT, Taha A, Elias GJB, Neudorfer C, Germann J, Paff M, Zrinzo L, Fasano A, Kalia SK, Steele CJ, Mikulis D, Kucharczyk W, Lozano AM. A literature review of magnetic resonance imaging sequence advancements in visualizing functional neurosurgery targets. J Neurosurg 2021; 135:1445-1458. [PMID: 33770759 DOI: 10.3171/2020.8.jns201125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Historically, preoperative planning for functional neurosurgery has depended on the indirect localization of target brain structures using visible anatomical landmarks. However, recent technological advances in neuroimaging have permitted marked improvements in MRI-based direct target visualization, allowing for refinement of "first-pass" targeting. The authors reviewed studies relating to direct MRI visualization of the most common functional neurosurgery targets (subthalamic nucleus, globus pallidus, and thalamus) and summarize sequence specifications for the various approaches described in this literature. METHODS The peer-reviewed literature on MRI visualization of the subthalamic nucleus, globus pallidus, and thalamus was obtained by searching MEDLINE. Publications examining direct MRI visualization of these deep brain stimulation targets were included for review. RESULTS A variety of specialized sequences and postprocessing methods for enhanced MRI visualization are in current use. These include susceptibility-based techniques such as quantitative susceptibility mapping, which exploit the amount of tissue iron in target structures, and white matter attenuated inversion recovery, which suppresses the signal from white matter to improve the distinction between gray matter nuclei. However, evidence confirming the superiority of these sequences over indirect targeting with respect to clinical outcome is sparse. Future targeting may utilize information about functional and structural networks, necessitating the use of resting-state functional MRI and diffusion-weighted imaging. CONCLUSIONS Specialized MRI sequences have enabled considerable improvement in the visualization of common deep brain stimulation targets. With further validation of their ability to improve clinical outcomes and advances in imaging techniques, direct visualization of targets may play an increasingly important role in preoperative planning.
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Affiliation(s)
- Alexandre Boutet
- 1University Health Network, Toronto
- 2Joint Department of Medical Imaging, University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | - Ludvic Zrinzo
- 3Functional Neurosurgery Unit, Department of Clinical and Movement Neurosciences, University College London, Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Alfonso Fasano
- 4Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto
- 5Krembil Brain Institute, Toronto, Ontario
| | | | - Christopher J Steele
- 6Department of Psychology, Concordia University, Montreal, Quebec, Canada; and
- 7Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - David Mikulis
- 1University Health Network, Toronto
- 2Joint Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Walter Kucharczyk
- 1University Health Network, Toronto
- 2Joint Department of Medical Imaging, University of Toronto, Ontario, Canada
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Fasano A, Eliashiv D, Herman ST, Lundstrom BN, Polnerow D, Henderson JM, Fisher RS. Experience and consensus on stimulation of the anterior nucleus of thalamus for epilepsy. Epilepsia 2021; 62:2883-2898. [PMID: 34697794 DOI: 10.1111/epi.17094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/31/2021] [Accepted: 09/27/2021] [Indexed: 12/11/2022]
Abstract
Deep brain stimulation of the anterior nuclei of thalamus (ANT-DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2-3-V or -mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off-label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT-DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.
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Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - Dawn Eliashiv
- Department of Neurology, UCLA Seizure Disorders Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Susan T Herman
- Epilepsy Program, Department of Neurology at Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | | | - Jaimie M Henderson
- Department of Neurosurgery and, by courtesy, Neurology and Neurological Sciences, Wu Tsai Neurosciences Institute and Bio-X Institute, Stanford University, Stanford, California, USA
| | - Robert S Fisher
- Department of Neurology & Neurological Sciences and, by courtesy, Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
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11
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Kaufmann E, Bötzel K, Vollmar C, Mehrkens JH, Noachtar S. What have we learned from 8 years of deep brain stimulation of the anterior thalamic nucleus? Experiences and insights of a single center. J Neurosurg 2021; 135:619-628. [PMID: 33126208 DOI: 10.3171/2020.6.jns20695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the absence of a standard or guideline for the treatment of epilepsy patients with deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT), systematic single-center investigations are essential to establish effective approaches. Here, the authors report on the long-term results of one of the largest single-center ANT DBS cohorts. METHODS The outcome data of 23 consecutive patients with transventricularly implanted electrodes were retrospectively analyzed with regard to adverse events, lead placement, stimulation-related side effects, and changes in seizure frequency. Depression and quality-of-life scores were collected in a subgroup of 9 patients. RESULTS All but 2 patients initially underwent bilateral implantation, and 84.4% of all DBS leads were successfully located within the ANT. The mean follow-up time was 46.57 ± 23.20 months. A seizure reduction > 50% was documented in 73.9% of patients, and 34.6% achieved an Engel class I outcome. In 3 patients, clinical response was achieved by switching the electrode contact or changing from the monopolar to bipolar stimulation mode. Unilateral implantation seemed ineffective, whereas bilateral stimulation with successful ANT implantation only on one side led to a clinical response. Double stimulation with additional vagus nerve stimulation was safe. Changes in cycling mode or stimulation amplitude influenced therapy tolerability and, only to a lesser extent, seizure frequency. Side effects were rare and typically vanished by lowering the stimulation amplitude or changing the active electrode contact. Furthermore, depression and aspects of quality of life significantly improved with ANT DBS treatment. CONCLUSIONS The transventricular approach as well as double stimulation proved safe. The anteroventral ANT appeared to be the most efficacious stimulation site. This systematic investigation with reluctant medication changes allowed for the development of a better idea of the association between parameter changes and outcome in ANT DBS patients, but larger samples are still needed to assess the potential of bipolar stimulation and distinct cycling frequencies. Furthermore, more multifaceted and objective assessments of treatment outcome are needed to fully assess the effects of ANT DBS treatment.
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Affiliation(s)
| | | | | | | | - Soheyl Noachtar
- 1Epilepsy Center, Department of Neurology; and Departments of
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12
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Basile GA, Bertino S, Bramanti A, Ciurleo R, Anastasi GP, Milardi D, Cacciola A. In Vivo Super-Resolution Track-Density Imaging for Thalamic Nuclei Identification. Cereb Cortex 2021; 31:5613-5636. [PMID: 34296740 DOI: 10.1093/cercor/bhab184] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 11/12/2022] Open
Abstract
The development of novel techniques for the in vivo, non-invasive visualization and identification of thalamic nuclei has represented a major challenge for human neuroimaging research in the last decades. Thalamic nuclei have important implications in various key aspects of brain physiology and many of them show selective alterations in various neurologic and psychiatric disorders. In addition, both surgical stimulation and ablation of specific thalamic nuclei have been proven to be useful for the treatment of different neuropsychiatric diseases. The present work aimed at describing a novel protocol for histologically guided delineation of thalamic nuclei based on short-tracks track-density imaging (stTDI), which is an advanced imaging technique exploiting high angular resolution diffusion tractography to obtain super-resolved white matter maps. We demonstrated that this approach can identify up to 13 distinct thalamic nuclei bilaterally with very high inter-subject (ICC: 0.996, 95% CI: 0.993-0.998) and inter-rater (ICC:0.981; 95% CI:0.963-0.989) reliability, and that both subject-based and group-level thalamic parcellation show a fair share of similarity to a recent standard-space histological thalamic atlas. Finally, we showed that stTDI-derived thalamic maps can be successfully employed to study structural and functional connectivity of the thalamus and may have potential implications both for basic and translational research, as well as for presurgical planning purposes.
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Affiliation(s)
- Gianpaolo Antonio Basile
- Brain Mapping Lab, Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98124 Messina, Italy
| | - Salvatore Bertino
- Brain Mapping Lab, Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98124 Messina, Italy
| | - Alessia Bramanti
- Department of Medicine, Surgery and Dentistry "Medical School of Salerno", University of Salerno, 84084 Baronissi, Italy
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi "Bonino Pulejo", 98124 Messina, Italy
| | - Giuseppe Pio Anastasi
- Brain Mapping Lab, Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98124 Messina, Italy
| | - Demetrio Milardi
- Brain Mapping Lab, Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98124 Messina, Italy
| | - Alberto Cacciola
- Brain Mapping Lab, Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98124 Messina, Italy
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13
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Yu K, Ren Z, Yu T, Wang X, Hu Y, Guo S, Li J, Li Y. Direct Targeting of the Anterior Nucleus of the Thalamus via 3 T Quantitative Susceptibility Mapping. Front Neurosci 2021; 15:685050. [PMID: 34290583 PMCID: PMC8287058 DOI: 10.3389/fnins.2021.685050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/17/2021] [Indexed: 12/18/2022] Open
Abstract
Objective: Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is a potentially effective, minimally invasive, and reversible method for treating epilepsy. The goal of this study was to explore whether 3 T quantitative susceptibility mapping (QSM) could delineate the ANT from surrounding structures, which is important for the direct targeting of DBS surgery. Methods: We obtained 3 T QSM, T1-weighted (T1w), and T2-weighted (T2w) images from 11 patients with Parkinson’s disease or dystonia who received subthalamic nucleus (STN) or globus pallidus interna (GPi) DBS surgery in our center. The ANT and its surrounding white matter structures on QSM were compared with available atlases. The contrast-to-noise ratios (CNRs) of ANT relative to the external medullary lamina (eml) were compared across the three imaging modalities. Additionally, the morphology and location of the ANT were depicted in the anterior commissure (AC)-posterior commissure (PC)-based system. Results: ANT can be clearly distinguished from the surrounding white matter laminas and appeared hyperintense on QSM. The CNRs of the ANT-eml on QSM, T1w, and T2w images were 10.20 ± 4.23, 1.71 ± 1.03, and 1.35 ± 0.70, respectively. One-way analysis of variance (ANOVA) indicated significant differences in CNRs among QSM, T1w, and T2w imaging modalities [F(2) = 85.28, p < 0.0001]. In addition, both the morphology and location of the ANT were highly variable between patients in the AC–PC-based system. Conclusion: The potential utility of QSM for the visualization of ANTs in clinical imaging is promising and may be suitable for targeting the ANT for DBS to treat epilepsy.
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Affiliation(s)
- Kaijia Yu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Zhiwei Ren
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Tao Yu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xueyuan Wang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yongsheng Hu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Song Guo
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Jianyu Li
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yongjie Li
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
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14
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Sobstyl M, Stapińska-Syniec A, Iwański S, Rylski M. Clinical Efficacy and Safety Profile of Anterior Thalamic Stimulation for Intractable Epilepsy. J Neurol Surg A Cent Eur Neurosurg 2021; 82:568-580. [PMID: 34126641 DOI: 10.1055/s-0041-1725954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Deep brain stimulation of the anterior nucleus of the thalamus (ANT DBS) is a neuromodulation therapy for patients with refractory partial seizures. The ANT is the structure of a limbic system with abundant neuronal connections to temporal and frontal brain regions that participate in seizure propagation circuitry. STATE OF THE ART We have performed a literature search regarding the clinical efficacy of ANT DBS. We discuss the surgical technique of the implantation of DBS electrodes with special attention paid to the targeting methods of the ANT. Moreover, we present in detail the clinical efficacy of ANT DBS, with a special emphasis on the stimulation parameters, a stimulation mode, and polarity. We also report all adverse events and present the current limitations of ANT DBS. CLINICAL IMPLICATIONS In general, the safety profile of DBS in intractable epilepsy patients is good, with a low rate of surgery, hardware-related, and stimulation-induced adverse events. No significant cognitive declines or worsening of depressive symptoms was noted. At long-term follow-up, the quality-of-life scores have improved. The limitations of ANT DBS studies include a limited number of patients treated and mostly open-label designs with only one double-blind, randomized multicenter trial. Most studies do not report the etiology of intractable epilepsy or they include nonhomogeneous groups of patients affected by intractable epilepsy. There are no guidelines for setting initial stimulation parameters. All the variables mentioned may have a profound impact on the final outcome. CONCLUSIONS ANT DBS appears to be a safe and efficacious treatment, particularly in patients with refractory partial seizures (three-quarters of patients gained at least 50% seizure reduction after 5 years). ANT DBS reduces most effectively the seizures originating in the temporal and frontal lobes. The published results of ANT DBS highlight promise and hope for patients with intractable epilepsy.
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Affiliation(s)
- Michał Sobstyl
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warszawa, Poland
| | | | - Szczepan Iwański
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warszawa, Poland
| | - Marcin Rylski
- Department of Neuroradiology, Institute of Psychiatry and Neurology, Warszawa, Poland.,Department of Clinical Cytology, Centrum Medyczne Ksztalcenia Podyplomowego, Warszawa, Poland
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15
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Anatomical connectivity and efficacy of electro-therapy for seizure control: A SANTE's single-center regression analyses. Epilepsy Behav 2021; 115:107709. [PMID: 33423018 DOI: 10.1016/j.yebeh.2020.107709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess based on a single-center data from a multicenter trial (Stimulation of the Anterior Nucleus for the Thalamus for Epilepsy (SANTE)), the role of anatomical connectivity and other factors (e.g., stimulating electrode placement) on efficacy of electro-therapy of the anterior thalamic nuclei (ATN), a node in Papez network, on pharmaco-resistant seizures. DATA SOURCE Adults with at least 6 seizures /month were enrolled in this trial. Percent seizure reduction was compared between subjects with seizures emerging inside Papez's network (IPN) to those with seizures outside it (OPN). Statistical analyses were performed on the first year of the trial. RESULTS Data from 11 subjects were analyzed. At Year 1, median seizure reduction was 80.5% (-100% to -40.3%) in 8/11 subjects with seizures IPN, vs. 52.8% (-61.4% to -23.7%) for 3/11 subjects with seizures OPN (2-sided Wilcoxon p = 0.08). At year 7, 3/11 subjects with seizures IPN had been seizure free for several years vs. 0/11 subjects with seizures OPN. Addition of 4 subjects from a pilot trial with nearly identical protocol to SANTE's, increased to 12/15 the number of subjects with seizures IPN. A 2-sided Fisher's exact test applied to seizure frequency reduction in the 12/15 cohort compared to the 3/15 with seizures OPN, showed significant (p = 0.04) differences in efficacy at the 70% seizure reduction rate. Median quality of life (QOL) scores for subjects with seizures IPN improved by 81% vs. 53% for subjects with seizures OPN. No other factors (e.g., current intensity) had a statistically significant effect on efficacy. CONCLUSIONS Degree of anatomical connectivity between stimulation targets and epileptogenic networks (ENs) plays an important role in therapeutic efficacy. This may be explained by the minimization of signal attenuation inherent in impulse transmission in nervous tissue partly as a function of fiber tract length, tissue anisotropy, and number of synaptic relays between stimulation target and epileptogenic networks.
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16
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Schaper FLWVJ, Plantinga BR, Colon AJ, Wagner GL, Boon P, Blom N, Gommer ED, Hoogland G, Ackermans L, Rouhl RPW, Temel Y. Deep Brain Stimulation in Epilepsy: A Role for Modulation of the Mammillothalamic Tract in Seizure Control? Neurosurgery 2021; 87:602-610. [PMID: 32421806 PMCID: PMC8210468 DOI: 10.1093/neuros/nyaa141] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/16/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) can improve seizure control for patients with drug-resistant epilepsy (DRE). Yet, one cannot overlook the high discrepancy in efficacy among patients, possibly resulting from differences in stimulation site. OBJECTIVE To test the hypothesis that stimulation at the junction of the ANT and mammillothalamic tract (ANT-MTT junction) increases seizure control. METHODS The relationship between seizure control and the location of the active contacts to the ANT-MTT junction was investigated in 20 patients treated with ANT-DBS for DRE. Coordinates and Euclidean distance of the active contacts relative to the ANT-MTT junction were calculated and related to seizure control. Stimulation sites were mapped by modelling the volume of tissue activation (VTA) and generating stimulation heat maps. RESULTS After 1 yr of stimulation, patients had a median 46% reduction in total seizure frequency, 50% were responders, and 20% of patients were seizure-free. The Euclidean distance of the active contacts to the ANT-MTT junction correlates to change in seizure frequency (r2 = 0.24, P = .01) and is ∼30% smaller (P = .015) in responders than in non-responders. VTA models and stimulation heat maps indicate a hot-spot at the ANT-MTT junction for responders, whereas non-responders had no evident hot-spot. CONCLUSION Stimulation at the ANT-MTT junction correlates to increased seizure control. Our findings suggest a relationship between the stimulation site and therapy response in ANT-DBS for epilepsy with a potential role for the MTT. DBS directed at white matter merits further exploration for the treatment of epilepsy.
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Affiliation(s)
- Frédéric L W V J Schaper
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Neurosurgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Birgit R Plantinga
- Department of Neurosurgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Albert J Colon
- Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Heeze, The Netherlands.,Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Louis Wagner
- Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Heeze, The Netherlands.,Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul Boon
- Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Heeze, The Netherlands.,Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | - Nadia Blom
- Department of Neurosurgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Erik D Gommer
- Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Govert Hoogland
- Department of Neurosurgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands.,Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Maastricht, The Netherlands
| | - Linda Ackermans
- Department of Neurosurgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands.,Academic Center for Epileptology Kempenhaeghe/ Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
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17
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Nome T, Herrman H, Lehtimäki K, Egge A, Konglund A, Ramm-Pettersen J, Taubøll E, Dietrichs E. Direct visual targeting versus preset coordinates for ANT-DBS in epilepsy. Acta Neurol Scand 2020; 142:23-29. [PMID: 32078161 DOI: 10.1111/ane.13233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Deep brain stimulation (DBS) of the anterior thalamic nucleus (ANT) may be used against refractory focal epilepsy, but only two randomized double-blinded trials have been performed. The Oslo study was discontinued prematurely since reduction in seizure frequency was less than expected. The aim of the present study was to review the targeting used in the Oslo study and to identify the actual positions of the contacts used for stimulation. MATERIAL AND METHODS BrainLab MRI data were available from 12 Oslo study patients. Based on MRI the coordinates of the center of the ANT were identified. The coordinates were considered as the visually identified preferred target and were compared with the target originally used for ANT electrode implantation and with the actual electrode positions estimated from post-operative CT scans. RESULTS We found considerable differences between the visually identified preferred target, the originally planned target, and the actual electrode position. The total distance between the active electrode position and the visually identified preferred target was on average 3.3 mm on the right and 2.9 mm on the left side. CONCLUSION Indirect targeting based on preset coordinates may contribute to explain the modest effect of ANT-DBS on seizure frequency seen in the Oslo study. Observed differences between the center of the ANT and the actual electrode position may at least in part be explained by variations in position and size of the ANT. Direct identification of the target using better MRI imaging protocols is recommended for future ANT-DBS surgery.
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Affiliation(s)
- Terje Nome
- Department of Radiology and Nuclear Medicine Oslo University Hospital Oslo Norway
| | - Helle Herrman
- Department of Neurology Oslo University Hospital Oslo Norway
- National Centre for Epilepsy Oslo University Hospital Oslo Norway
- Faculty of Medicine University of Oslo Oslo Norway
| | - Kai Lehtimäki
- Department of Neurosciences and Rehabilitation Tampere University Hospital Tampere Norway
| | - Arild Egge
- Department of Neurosurgery Oslo University Hospital Oslo Norway
| | - Ane Konglund
- Department of Neurosurgery Oslo University Hospital Oslo Norway
| | | | - Erik Taubøll
- Department of Neurology Oslo University Hospital Oslo Norway
- Faculty of Medicine University of Oslo Oslo Norway
| | - Espen Dietrichs
- Department of Neurology Oslo University Hospital Oslo Norway
- Faculty of Medicine University of Oslo Oslo Norway
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18
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Grewal SS, Middlebrooks EH, Okromelidze L, Gosden GP, Tatum WO, Lundstrom BN, Worrell GA, Wharen RE, Van Gompel JJ. Variability Between Direct and Indirect Targeting of the Anterior Nucleus of the Thalamus. World Neurosurg 2020; 139:e70-e77. [PMID: 32302732 DOI: 10.1016/j.wneu.2020.03.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Preoperative thalamic targeting methods have historically relied on indirect targeting techniques that do not fully account for variances in anatomy or for thalamic atrophy in epilepsy. We aimed to address variability noted between traditional indirect targeting and direct targeting methods for the anterior nucleus of the thalamus (ANT). METHODS Fifteen consecutive patients undergoing ANT deep brain stimulator placement were evaluated (30 thalamic nuclei). Direct ANT targeting was performed using a fast gray matter acquisition T1 inversion recovery sequence and compared with standard stereotactic coordinates. Thalamic volumes were calculated for each patient, and degree of thalamic volume loss was assessed compared with matched control subjects. Vertex analysis was performed to assess shape changes in the thalamus compared with age- and sex-matched subjects. RESULTS There was significant variation between direct and indirect targets in the y-axis and z-axis on both sides. On the left, the direct target was located at y = 2 ± 1.3 mm and z = 9.3 ± 1.8 mm (both P = 0.02). On the right, the direct target was located at y = 2.9 ± 1.8 mm and z = 9.2 ± 2 mm (both P ≤ 0.0003). There was no significant difference in the x-coordinate on either side (P > 0.5). Additionally, there was a correlation between thalamic volume and difference between direct and indirect targets in the y-axis and the z-axis. CONCLUSIONS We showed a significant difference in direct and indirect targeting in the y-axis and z-axis when targeting the ANT for deep brain stimulation for epilepsy. This difference is correlated to thalamic volume, with a larger difference noted in patients with thalamic atrophy.
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Affiliation(s)
- Sanjeet S Grewal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Lela Okromelidze
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Grant P Gosden
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Robert E Wharen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
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19
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Beaumont J, Saint-Jalmes H, Acosta O, Kober T, Tanner M, Ferré JC, Salvado O, Fripp J, Gambarota G. Multi T1-weighted contrast MRI with fluid and white matter suppression at 1.5 T. Magn Reson Imaging 2019; 63:217-225. [PMID: 31425812 DOI: 10.1016/j.mri.2019.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/11/2019] [Accepted: 08/15/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The fluid and white matter suppression sequence (FLAWS) provides two T1-weighted co-registered datasets: a white matter (WM) suppressed contrast (FLAWS1) and a cerebrospinal fluid (CSF) suppressed contrast (FLAWS2). FLAWS has the potential to improve the contrast of the subcortical brain regions that are important for Deep Brain Stimulation surgery planning. However, to date FLAWS has not been optimized for 1.5 T. In this study, the FLAWS sequence was optimized for use at 1.5 T. In addition, the contrast-enhancement properties of FLAWS image combinations were investigated using two voxel-wise FLAWS combined images: the division (FLAWS-div) and the high contrast (FLAWS-hc) image. METHODS FLAWS sequence parameters were optimized for 1.5 T imaging using an approach based on the use of a profit function under constraints for brain tissue signal and contrast maximization. MR experiments were performed on eleven healthy volunteers (age 18-30). Contrast (CN) and contrast to noise ratio (CNR) between brain tissues were measured in each volunteer. Furthermore, a qualitative assessment was performed to ensure that the separation between the internal globus pallidus (GPi) and the external globus pallidus (GPe) is identifiable in FLAWS1. RESULTS The optimized set of sequence parameters for FLAWS at 1.5 T provided contrasts similar to those obtained in a previous study at 3 T. The separation between the GPi and the GPe was clearly identified in FLAWS1. The CN of FLAWS-hc was higher than that of FLAWS1 and FLAWS2, but was not different from the CN of FLAWS-div. The CNR of FLAWS-hc was higher than that of FLAWS-div. CONCLUSION Both qualitative and quantitative assessments validated the optimization of the FLAWS sequence at 1.5 T. Quantitative assessments also showed that FLAWS-hc provides an enhanced contrast compared to FLAWS1 and FLAWS2, with a higher CNR than FLAWS-div.
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Affiliation(s)
- J Beaumont
- Univ Rennes, CLCC Eugène Marquis, Inserm, LTSI-UMR1099, F-35000 Rennes, France; CSIRO, the Australian eHealth Research Centre, Herston, Queensland, Australia.
| | - H Saint-Jalmes
- Univ Rennes, CLCC Eugène Marquis, Inserm, LTSI-UMR1099, F-35000 Rennes, France
| | - O Acosta
- Univ Rennes, CLCC Eugène Marquis, Inserm, LTSI-UMR1099, F-35000 Rennes, France
| | - T Kober
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland; Department of Radiology, University Hospital (CHUV), Lausanne, Switzerland; LTS5, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - M Tanner
- Invicro, A Konica Minolta Company, London, UK
| | - J C Ferré
- Univ Rennes, Inria, CNRS, INSERM, IRISA, VISAGES ERL U-1228, F-35000 Rennes, France; CHU Rennes, Department of Neuroradiology, F-35033 Rennes, France
| | - O Salvado
- CSIRO, Data61, Herston, Queensland, Australia
| | - J Fripp
- CSIRO, the Australian eHealth Research Centre, Herston, Queensland, Australia
| | - G Gambarota
- Univ Rennes, CLCC Eugène Marquis, Inserm, LTSI-UMR1099, F-35000 Rennes, France
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20
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Bouwens van der Vlis TAM, Schijns OEMG, Schaper FLWVJ, Hoogland G, Kubben P, Wagner L, Rouhl R, Temel Y, Ackermans L. Deep brain stimulation of the anterior nucleus of the thalamus for drug-resistant epilepsy. Neurosurg Rev 2019; 42:287-296. [PMID: 29306976 PMCID: PMC6502776 DOI: 10.1007/s10143-017-0941-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/13/2017] [Accepted: 12/19/2017] [Indexed: 12/17/2022]
Abstract
Despite the use of first-choice anti-epileptic drugs and satisfactory seizure outcome rates after resective epilepsy surgery, a considerable percentage of patients do not become seizure free. ANT-DBS may provide for an alternative treatment option in these patients. This literature review discusses the rationale, mechanism of action, clinical efficacy, safety, and tolerability of ANT-DBS in drug-resistant epilepsy patients. A review using systematic methods of the available literature was performed using relevant databases including Medline, Embase, and the Cochrane Library pertaining to the different aspects ANT-DBS. ANT-DBS for drug-resistant epilepsy is a safe, effective and well-tolerated therapy, where a special emphasis must be given to monitoring and neuropsychological assessment of both depression and memory function. Three patterns of seizure control by ANT-DBS are recognized, of which a delayed stimulation effect may account for an improved long-term response rate. ANT-DBS remotely modulates neuronal network excitability through overriding pathological electrical activity, decrease neuronal cell loss, through immune response inhibition or modulation of neuronal energy metabolism. ANT-DBS is an efficacious treatment modality, even when curative procedures or lesser invasive neuromodulative techniques failed. When compared to VNS, ANT-DBS shows slightly superior treatment response, which urges for direct comparative trials. Based on the available evidence ANT-DBS and VNS therapies are currently both superior compared to non-invasive neuromodulation techniques such as t-VNS and rTMS. Additional in-vivo research is necessary in order to gain more insight into the mechanism of action of ANT-DBS in localization-related epilepsy which will allow for treatment optimization. Randomized clinical studies in search of the optimal target in well-defined epilepsy patient populations, will ultimately allow for optimal patient stratification when applying DBS for drug-resistant patients with epilepsy.
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Affiliation(s)
- Tim A M Bouwens van der Vlis
- Department of Neurosurgery, Academic Center for Epileptology (ACE), Maastricht University Medical Center, Maastricht (MUMC), PO Box 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Olaf E M G Schijns
- Department of Neurosurgery, Academic Center for Epileptology (ACE), Maastricht University Medical Center, Maastricht (MUMC), PO Box 5800, 6202, AZ, Maastricht, The Netherlands
- European Graduate School of Neuroscience (Euron), Maastricht University, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Frédéric L W V J Schaper
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Academic Center for Epileptology (ACE), Kempenhaeghe, MUMC, Maastricht, The Netherlands
| | - Govert Hoogland
- Department of Neurosurgery, Academic Center for Epileptology (ACE), Maastricht University Medical Center, Maastricht (MUMC), PO Box 5800, 6202, AZ, Maastricht, The Netherlands
- European Graduate School of Neuroscience (Euron), Maastricht University, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Pieter Kubben
- Department of Neurosurgery, Academic Center for Epileptology (ACE), Maastricht University Medical Center, Maastricht (MUMC), PO Box 5800, 6202, AZ, Maastricht, The Netherlands
| | - Louis Wagner
- Department of Neurology, Academic Center for Epileptology (ACE), Kempenhaeghe, MUMC, Maastricht, The Netherlands
| | - Rob Rouhl
- European Graduate School of Neuroscience (Euron), Maastricht University, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Academic Center for Epileptology (ACE), Kempenhaeghe, MUMC, Maastricht, The Netherlands
- Academic Center for Epileptology MUMC+ and Kempenhaeghe, Heeze, Maastricht, The Netherlands
| | - Yasin Temel
- Department of Neurosurgery, Academic Center for Epileptology (ACE), Maastricht University Medical Center, Maastricht (MUMC), PO Box 5800, 6202, AZ, Maastricht, The Netherlands
- European Graduate School of Neuroscience (Euron), Maastricht University, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Linda Ackermans
- Department of Neurosurgery, Academic Center for Epileptology (ACE), Maastricht University Medical Center, Maastricht (MUMC), PO Box 5800, 6202, AZ, Maastricht, The Netherlands
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Wang YC, Grewal SS, Middlebrooks EH, Worrell GA, Stead M, Lundstrom BN, Britton JW, Wu MH, Van Gompel JJ. Targeting analysis of a novel parietal approach for deep brain stimulation of the anterior nucleus of the thalamus for epilepsy. Epilepsy Res 2019; 153:1-6. [PMID: 30913474 DOI: 10.1016/j.eplepsyres.2019.03.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/02/2019] [Accepted: 03/18/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is a promising treatment for refractory epilepsy; however, it remains challenging to successfully target the ANT. The results of Medtronic Registry for Epilepsy (MORE) supported a frontal transventricular(TV) compared to frontal extraventricular (EV) lead trajectory for ANT DBS may have better coverage of the ANT. Here we report the safety and targeting efficacy of a novel, posterior parietal extraventricular (PEV) approach to the ANT. METHODS We conducted a retrospective analysis of ten patients who underwent bilateral ANT DBS (20 total trajectories) for medically-refractory epilepsy. Similar targeting methodology as the MORE trial was used, and the DBS Intrinsic Template Atlas (DISTAL) was utilized for ANT localization and contact position relative to ANT. Clinical data were assessed for DBS targeting efficacy and surgical complications. RESULTS The demonstrated PEV trajectory showed a successful ANT targeting rate of 90% bilaterally. Two or more contacts within ANT were presented in 75% of all leads. Mean contact number in ANT was 2.2+ 1.2. There were no intracranial hemorrhages, cerebrospinal fluid leakage, or permanent neurologic deficits. CONCLUSION In this small series, the novel PEV for ANT DBS is feasible with good targeting accuracy and potential safety advantages. The high accuracy of the PEV trajectory suggests that it is a reasonable alternative trajectory for ANT DBS. Larger studies will be needed to assess this trajectory on clinical outcome of DBS treatment to epilepsy.
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Affiliation(s)
- Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital in Linkou, Chang Gung University, Taiwan; Program of Biomedical Engineering, Graduate Institute of Biomedical Engineering, Chang Gung University, Taiwan
| | | | - Erik H Middlebrooks
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA; Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Matt Stead
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Min-Hsien Wu
- Program of Biomedical Engineering, Graduate Institute of Biomedical Engineering, Chang Gung University, Taiwan
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Grewal SS, Middlebrooks EH, Kaufmann TJ, Stead M, Lundstrom BN, Worrell GA, Lin C, Baydin S, Van Gompel JJ. Fast gray matter acquisition T1 inversion recovery MRI to delineate the mammillothalamic tract for preoperative direct targeting of the anterior nucleus of the thalamus for deep brain stimulation in epilepsy. Neurosurg Focus 2018; 45:E6. [DOI: 10.3171/2018.4.focus18147] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
When medically intractable epilepsy is multifocal or focal but poorly localized, neuromodulation can be useful therapy. One such technique is deep brain stimulation (DBS) targeting the anterior nucleus of the thalamus (ANT). Unfortunately, the ANT is difficult to visualize in standard MRI sequences and its indirect targeting is difficult because of thalamic variability and atrophy in patients with epilepsy. The following study describes the novel use of the fast gray matter acquisition T1 inversion recovery (FGATIR) MRI sequence to delineate the mammillothalamic tract for direct targeting of the ANT through visualizing the termination of the mammillothalamic tract in the ANT.The day prior to surgery in a 19-year-old, right-handed woman with a 5-year history of epilepsy, MRI was performed on a 3-T Siemens Prisma scanner (Siemens AG, Healthcare Sector) using a 64-channel head and neck coil. As part of the imaging protocol, noncontrast magnetization-prepared rapid gradient echo (MP-RAGE) and diffusion tensor imaging (DTI) sequences were obtained for targeting purposes. The ANT was directly targeted using the FGATIR sequence, and bilateral Medtronic 3389 leads were placed. At the last follow-up (2 months), the patient reported an approximate 75% decrease in seizure frequency, as well as a decrease in seizure severity.
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Affiliation(s)
| | | | | | | | | | | | - Chen Lin
- 2Radiology, Mayo Clinic, Jacksonville, Florida
| | - Serhat Baydin
- 5Department of Neurosurgery, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
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Sitnikov AR, Grigoryan YA, Mishnyakova LP. Bilateral stereotactic lesions and chronic stimulation of the anterior thalamic nuclei for treatment of pharmacoresistant epilepsy. Surg Neurol Int 2018; 9:137. [PMID: 30105131 PMCID: PMC6069370 DOI: 10.4103/sni.sni_25_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/21/2018] [Indexed: 12/18/2022] Open
Abstract
Background: The use of the anterior nucleus of thalamus (ANT) as a target for treatment of pharmacoresistant epilepsy is based on its crucial role in seizure propagation. We describe results of chronic bilateral ANT stimulation and bilateral ANT lesions in 31 patients with refractory epilepsy. Methods: ANT DBS was performed in 12 patients (group I) and bilateral stereotactic radiofrequency lesions of ANT were performed in 19 patients (group II). Targeting was based on stereotactic atlas information with correction of the final coordinates according to the location of anatomical landmarks and intraoperative microelectrode recording data. Results: Both groups were similar in age, gender, seizures frequency, and duration of disease. The median x, y, and z coordinates of ANT were found to be 2.9, 5, and 11 mm anterior, lateral, and superior to the mid-commissural point, respectively. Mean seizures reduction reached 80.3% in group of patients with ANT DBS with two nonresponders and 91.2% in group of patients with lesions. Five patients from group I and three patients from group II became seizure-free. The morbidity rate was low in both groups. Conclusions: Stereotactic anterior thalamotomy and chronic ANT stimulation are both effective for seizure control in epilepsy originated from frontal and temporal lobes. ANT lesions and stimulation were more effective for secondary-generalized seizures compared to simple partial seizures.
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Affiliation(s)
- A R Sitnikov
- Federal Centre of Treatment and Rehabilitation of Ministry of Healthcare of Russian Federation, Ivankovskoe, Moscow, Russia
| | - Yu A Grigoryan
- Federal Centre of Treatment and Rehabilitation of Ministry of Healthcare of Russian Federation, Ivankovskoe, Moscow, Russia
| | - L P Mishnyakova
- Federal Centre of Treatment and Rehabilitation of Ministry of Healthcare of Russian Federation, Ivankovskoe, Moscow, Russia
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Koch P, Baltuch G. Deep Brain Stimulation for Epilepsy. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00083-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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