Quantification and Visualization of Three-Dimensional Inconsistency of the Globus Pallidus Internus in the Schaltenbrand-Wahren Brain Atlas

Intraoperative electrophysiological monitoring determines the final electrode position for pallidal stimulation in dystonia patients

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).

Defining the optimal target for anterior thalamic deep brain stimulation in patients with drug-refractory epilepsy

OBJECTIVE

The anterior thalamic nucleus (ATN) is a common target for deep brain stimulation (DBS) for the treatment of drug-refractory epilepsy. However, no atlas-based optimal DBS (active contacts) target within the ATN has been definitively identified. The object of this retrospective study was to analyze the relationship between the active contact location and seizure reduction to establish an atlas-based optimal target for ATN DBS.

METHODS

From among 25 patients who had undergone ATN DBS surgery for drug-resistant epilepsy between 2016 and 2018, those who had follow-up evaluations for more than 1 year were eligible for study inclusion. After an initial stimulation period of 6 months, patients were classified as responsive (≥ 50% median decrease in seizure frequency) or nonresponsive (< 50% median decrease in seizure frequency) to treatment. Stimulation parameters and/or active contact positions were adjusted in nonresponsive patients, and their responsiveness was monitored for at least 1 year. Postoperative CT scans were coregistered nonlinearly with preoperative MR images to determine the center coordinate and atlas-based anatomical localizations of all active contacts in the Montreal Neurological Institute (MNI) 152 space.

RESULTS

Nineteen patients with drug-resistant epilepsy were followed up for at least a year following bilateral DBS electrode implantation targeting the ATN. Active contacts located more adjacent to the center of gravity of the anterior half of the ATN volume, defined as the anterior center (AC), were associated with greater seizure reduction than those not in this location. Intriguingly, the initially nonresponsive patients could end up with much improved seizure reduction by adjusting the active contacts closer to the AC at the final postoperative follow-up.

CONCLUSIONS

Patients with stimulation targeting the AC may have a favorable seizure reduction. Moreover, the authors were able to obtain additional good outcomes after electrode repositioning in the initially nonresponsive patients. Purposeful and strategic trajectory planning to target this optimal region may predict favorable outcomes of ATN DBS.

Human brain atlasing: past, present and future

We have recently witnessed an explosion of large-scale initiatives and projects addressing mapping, modeling, simulation and atlasing of the human brain, including the BRAIN Initiative, the Human Brain Project, the Human Connectome Project (HCP), the Big Brain, the Blue Brain Project, the Allen Brain Atlas, the Brainnetome, among others. Besides these large and international initiatives, there are numerous mid-size and small brain atlas-related projects. My contribution to these global efforts has been to create adult human brain atlases in health and disease, and to develop atlas-based applications. For over two decades with my R&D lab I developed 35 brain atlases, licensed to 67 companies and made available in about 100 countries. This paper has two objectives. First, it provides an overview of the state of the art in brain atlasing. Second, as it is already 20 years from the release of our first brain atlas, I summarise my past and present efforts, share my experience in atlas creation, validation and commercialisation, compare with the state of the art, and propose future directions.

Targeting of the Subthalamic Nucleus for Deep Brain Stimulation: A Survey Among Parkinson Disease Specialists

BACKGROUND

Deep brain stimulation within or adjacent to the subthalamic nucleus (STN) represents the most common stereotactic procedure performed for Parkinson disease. Better STN imaging is often regarded as a requirement for improving stereotactic targeting. However, it is unclear whether there is consensus about the optimal target.

METHODS

To obtain an expert opinion on the site regarded optimal for "STN stimulation," movement disorder specialists were asked to indicate their preferred position for an active contact on hard copies of the Schaltenbrand and Wahren atlas depicting the STN in all 3 planes. This represented an idealized setting, and it mimicked optimal imaging for direct target definition in a perfectly delineated STN.

RESULTS

The suggested targets were heterogeneous, although some clustering was observed in the dorsolateral STN and subthalamic area. In particular, in the anteroposterior direction, the intended targets differed to a great extent. Most of the indicated targets are thought to also result in concomitant stimulation of structures adjacent to the STN, including the zona incerta, fields of Forel, and internal capsule.

CONCLUSIONS

This survey illustrates that most sites regarded as optimal for STN stimulation are close to each other, but there appears to be no uniform perception of the optimal anatomic target, possibly influencing surgical results. The anatomic sweet zone for STN stimulation needs further specification, as this information is likely to make magnetic resonance imaging-based target definition less variable when applied to individual patients.

What You See Is What You Get: Lead Location Within Deep Brain Structures Is Accurately Depicted by Stereotactic Magnetic Resonance Imaging

BACKGROUND

Magnetic resonance imaging (MRI)-verified deep brain stimulation relies on the correct interpretation of stereotactic imaging documenting lead location in relation to visible anatomic target. However, it has been suggested that local signal distortion from the lead itself renders its depiction on MRI unreliable.

OBJECTIVE

To compare lead location on stereotactic MRI with subsequent location of its brain track after removal.

METHODS

Patients underwent deep brain stimulation with the use of MRI-guided and MRI-verified Leksell frame approach. Infection or suboptimal efficacy required lead removal and subsequent reimplantation by using the same technique. Postimplantation stereotactic MR images were analyzed. Lateral (x) and anteroposterior (y) distances from midcommissural point to center of the lead hypointensity were recorded at the anterior commissure-posterior commissure plane (pallidal electrode) or z = -4 (subthalamic electrode). Stereotactic MRI before the second procedure, x and y distances from the center of the visible lead track hypointensity to midcommissural point were independently recorded. Vectorial distance from center of the lead hypointensity to the center of its track was calculated.

RESULTS

Sixteen electrode tracks were studied in 10 patients. Mean differences between lead artifact location and lead track location were: x coordinate 0.4 mm ± 0.2; y coordinate 0.6 mm ± 0.3. Mean vectorial distance was 0.7 mm ± 0.2.

CONCLUSION

Stereotactic distance between lead location and subsequent brain track location on MRI was small. The mean discrepancy was approximately half the deep brain stimulation lead width. This suggests that lead hypointensity seen on postimplantation MRI is indeed an accurate representation of its real location within deep brain structures.

Improving targeting in image-guided frame-based deep brain stimulation

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.

Transcranial sonographic localization of deep brain stimulation electrodes is safe, reliable and predicts clinical outcome

In patients with deep brain stimulation (DBS), poor postoperative outcome or unexpected clinical change require brain imaging to check the lead location. Here, we studied safety, reliability and prognostic value of transcranial sonography (TCS) for DBS lead localization applying predefined TCS criteria. After measuring thermal effects of TCS and imaging artefact sizes of DBS lead using a skull phantom, we prospectively enrolled 34 patients with DBS of globus pallidus internus, ventro-intermediate thalamic or subthalamic nucleus. TCS had no influence on lead temperature, electrical parameters of DBS device or clinical state of patients. TCS measures of lead coordinates agreed with MRI measures in anterior-posterior and medial-lateral axis. Lead dislocation requiring reinsertion was reliably detected. Only patients with optimal lead position on TCS had favorable clinical 12-month outcome (>50% improvement), whereas unfavorable outcome (<25% improvement) was associated with suboptimal lead position. TCS may therefore become a first-choice modality to monitor lead location.

Quantification of spatial consistency in the Talairach and Tournoux stereotactic atlas

BACKGROUND

The Talairach-Tournoux (TT) atlas is one of the most prevalent brain atlases. Although its spatial inconsistencies were reported earlier, there has been no systematic quantification of them across the entire atlas, which is addressed here.

METHOD

The consistency of the TT atlas, defined as uniformity of labeling across all three orthogonal atlas orientations, is calculated and presented as maps. It is analyzed in function of discrepancy measuring spatial offset in labeling.

FINDINGS

The TT atlas has 27.4% consistency and 37.7% inconsistency. The most consistent structure is the thalamus (85.7% consistency, 5.4% inconsistency). The consistency of the basal ganglia is good. For 3-mm discrepancy, the inconsistency of major subcortical gray matter structures is very low: 0% (globus pallidus medial and putamen), 0.7% (thalamus), 2.2% (globus pallidus lateral), 4.8% (hippocampus) and 4.9% (caudate nucleus). The inconsistency of all subcortical structures is relatively high (16.8%), caused by a very high inconsistency of white matter tracts. The consistency of stereotactic targets is 69.2% (GPi), 50.0% (STN) and 42.9% (VPL). The overall TT consistency increases by 20% for 1-mm discrepancy, constantly grows by 10% for 2-4-mm discrepancy and slows down to 3% for 5-6-mm discrepancy.

CONCLUSION

This work enhances our understanding of the TT atlas and its variable spatial consistency. It is helpful in using multiple atlas orientations simultaneously. It also may be useful in atlas interpolation and construction of a fully consistent 3D atlas. As the consistency of the main stereotactic targets is medium, the use of the TT atlas in stereotactic procedures requires a great deal of care and understanding of its limitations.

Quantification and visualization of three-dimensional inconsistency of the ventrointermediate nucleus of the thalamus in the Schaltenbrand-Wahren brain atlas

BACKGROUND

This work quantifies and visualises 3D inconsistencies of the ventrointermediate nucleus (VIM) of the thalamus, including the VIM externum (VIMe) and VIM internum (VIMi), in the Schaltenbrand-Wahren (SW) brain atlas.

METHOD

For each VIM, VIMe, VIMi the 3D models, 3D-A, 3D-C and 3D-S were reconstructed from the SW axial, coronal and sagittal microseries, respectively, by applying a shape-based method. All 3D models, placed in the SW coordinate system, were compared quantitatively in terms of location (centroids), size (volumes), shape (normalised eigen values), orientation (eigen vectors), and mutual spatial relationships (overlaps and inclusions).

FINDINGS

The reconstructed 3D models differ significantly in location, size, shape, and inclusion rate. The centroid of 3D-A/VIM differs considerably from those of 3D-C/VIM and 3D-S/VIM. The difference between the centroids of 3D-C/VIM and 3D-S/VIM is in laterality only: that of 3D-C/VIM is located more medially (11.85 mm) than that of 3D-S/VIM (14.62 mm). 3D-A/VIM has the smallest volume (69.00 mm(3)); 3D-C/VIM is 3.71 and 3D-S/VIM 3.89 times larger. The overlap is also highly variable: 104.88 mm(3) for 3D-C/VIM with 3D-S/VIM, and very low (3.22 and 7.45 mm(3)) when 3D-A/VIM is involved. The highest inclusion rate is for 3D-C/VIM with 3D-S/VIM (39.10 and 40.97%) and the lowest for 3D-A/VIM with 3D-C/VIM (1.26 and 4.66%). The centroid of 3D-A/VIMe differs noticeably from those of 3D-C/VIMe and 3D-S/VIMe. The difference between the centroids of 3D-C/VIMe and 3D-S/VIMe is mainly in laterality: that of 3D-C/VIMe is located more medially (12.91 mm) than that of 3D-S/VIMe (16.65 mm). 3D-A/VIMe has the smallest volume (49.87 mm(3)); 3D-S/VIMe is 3.24 and 3D-C/VIMe 3.36 times larger. The overlap sizes are low: 32.72 mm(3) for 3D-C/VIMe with 3D-S/VIMe, and very low (1.32 and 2.01 mm(3)) when 3D-A/VIMe is involved. The inclusion rates are also low: the highest is for 3D-C/VIMe with 3D-S/VIMe (19.53 and 20.29%) and the lowest for 3D-A/VIMe with 3D-C/VIMe (1.19 and 4.01%). Lateral scaling of the coronal microseries by 1.2897 to match the 3D-C/VIMe and 3D-S/VIMe centroids increases the inclusion rates for the sagittal microseries by more than twice. The volume of scaled 3D-C enlarges to 216.24 mm(3) which is 1.34 bigger than that of 3D-S. There are substantial differences among the centroids of 3D-A/VIMi, 3D-C/VIMi and 3D-S/VIMi. The centroid of 3D-A/VIMi is located more anteriorly (-1.92 mm) than that of 3D-C/VIMi (-5.02 mm). The centroid of 3D-A/VIMi is located more ventrally (2.88 mm) than those of 3D-C/VIMi and 3D-S/VIMi (each at 5.34 mm). 3D-A/VIMi has the smallest volume (19.75 mm(3)); 3D-S/VIMi is 3.23 and 3D-C/VIMi 4.30 times larger. 3D-A/VIMi practically does not overlap with 3D-C/VIMi and 3D-S/VIMi. The inclusion rates for 3D-C/VIMi with 3D-S/VIMi are medium (32.63 and 43.43%).

CONCLUSION

Each VIM, VIMe, VIMi as reconstructed from the SW atlas has a significant 3D inaccuracy within each orientation and across them. Therefore, absolute and direct reliance on the original SW atlas is unreliable and unsafe, and this atlas has to be used with great care and understanding of its strengths and limitations.

Towards construction of an ideal stereotactic brain atlas

BACKGROUND

The role of the brain atlas is changing in many aspects with the advancements in stereotactic and functional neurosurgery. Therefore, there is a critical need to construct a new atlas. This paper addresses the definition and construction of an atlas, ideal (in our opinion) for stereotactic and functional neurosurgery. The essence of the new atlas is not only its population-based structural and functional content, but also its continuous "self-updatability" with the new clinical results obtained.

METHOD

The ideal atlas defined here contains four major components: brain models, knowledge database, tools, and clinical results. Towards its creation, a multi-atlas is proposed. The construction of the initial version of the multi-atlas is detailed with the probabilistic functional atlas (PFA), interpolated Talairach-Tournoux atlas, and enhanced Schaltenbrand-Wahren atlas. These atlases are put in a spatial register by matching their AC-PC distances and heights of the thalamus; the Schaltenbrand coronal and sagittal microseries are scaled laterally to match the target structure centroids with the locations of the best targets of the PFA.

FINDINGS

Construction of an initial version of the ideal stereotactic atlas is feasible at present from the available resources. To achieve that, our three atlases (PFA, Talairach and Schaltenbrand) are enhanced and combined together. A single lateral scaling factor per target structure is feasible to co-register the Schaltenbrand atlas with PFA in four situations (compensated against the third ventricle, non-compensated, bilateral, and non-bilateral). The STN has to be stretched by 18% more than the VIM on the Schaltenbrand coronal microseries, and the VIM has to be compressed by 13% less than the STN on the Schaltenbrand sagittal microseries.

CONCLUSION

The new multi-atlas can potentially be more useful than the currently employed atlases and will facilitate further development of the ideal atlas for stereotactic and functional neurosurgery.