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Bolier E, Holewijn R, De Bie RMA, Beudel M, van den Munckhof P, Schuurman R, Bot M. Validation of the hotspot for dorsolateral subthalamic nucleus targeting in deep brain stimulation surgery for Parkinson's disease: a post hoc analysis of a randomised controlled trial. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333164. [PMID: 39033020 DOI: 10.1136/jnnp-2023-333164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Visualisation of the dorsolateral subthalamic nucleus (STN) remains challenging on 1.5 and 3Tesla T2-weighted MRI. Our previously defined hotspot, relative to the well-visualised medial STN border, serves as an MRI landmark for dorsolateral STN identification in deep brain stimulation (DBS). We aimed to validate this hotspot in a separate trial cohort of Parkinson's disease (PD) patients and refine its location. METHODS In this post hoc analysis of a randomised controlled trial, in which the hotspot was taken into account during target planning, responses to DBS were evaluated using hemibody improvement on the Movement Disorder Society-Unified Parkinson's Disease Rating Scale motor examination and compared with our historical cohort, as well as dopaminergic medication reduction. Then, a refined hotspot was calculated and the Euclidean distance from individual active contacts to the refined hotspot was correlated with motor improvement. RESULTS The first quartile of the hemibodies (poor responders) showed an average improvement of 13%, which was higher than the -8% in the historical control group (p=0.044). Dopaminergic medication reduction was greater in the current cohort compared with the historical cohort (p=0.020). Overall variability of hemibody motor improvement was reduced in the current cohort compared with the historical control group (p=0.003). Motor improvement correlated to the Euclidean distance from active contact to the refined hotspot (2.8 mm lateral, 1.1 mm anterior and 2.2 mm superior to the medial STN border) (p=0.001). CONCLUSION We validated the hotspot for dorsolateral STN targeting in DBS for patients with PD and showed an improved motor response in poor responders, a reduced variability in motor improvement and a greater dopaminergic medication reduction. We then refined the hotspot at 2.8 mm lateral, 1.1 mm anterior and 2.2 mm superior relative to the medial STN border, which visualises a readily implementable target within the dorsolateral STN on lower field strength MRI.
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Affiliation(s)
- Erik Bolier
- Neurosurgery, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | | | - Rob M A De Bie
- Neurology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Martijn Beudel
- Neurology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | | | - Richard Schuurman
- Neurosurgery, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Maarten Bot
- Neurosurgery, Amsterdam University Medical Centres, Amsterdam, Netherlands
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Tonroe T, McDermott H, Pearce P, Acevedo N, Thevathasan W, Xu SS, Bulluss K, Perera T. Anatomical targeting for electrode localization in subthalamic nucleus deep brain stimulation: A comparative study. J Neuroimaging 2023; 33:792-801. [PMID: 37288952 PMCID: PMC10946722 DOI: 10.1111/jon.13133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND AND PURPOSE In deep brain stimulation (DBS), accurate electrode placement is essential for optimizing patient outcomes. Localizing electrodes enables insight into therapeutic outcomes and development of metrics for use in clinical trials. Methods of defining anatomical targets have been described with varying accuracy and objectivity. To assess variability in anatomical targeting, we compare four methods of defining an appropriate target for DBS of the subthalamic nucleus for Parkinson's disease. METHODS The methods compared are direct visualization, red nucleus-based indirect targeting, mid-commissural point-based indirect targeting, and automated template-based targeting. This study assessed 226 hemispheres in 113 DBS recipients (39 females, 73 males, 62.2 ± 7.7 years). We utilized the electrode placement error (the Euclidean distance between the defined target and closest DBS electrode) as a metric for comparative analysis. Pairwise differences in electrode placement error across the four methods were compared using the Kruskal-Wallis H-test and Wilcoxon signed-rank tests. RESULTS Interquartile ranges of the differences in electrode placement error spanned 1.18-1.56 mm. A Kruskal-Wallis H-test reported a statistically significant difference in the median of at least two groups (H(5) = 41.052, p < .001). Wilcoxon signed-rank tests reported statistically significant difference in two comparisons: direct visualization versus red nucleus-based indirect, and direct visualization versus automated template-based methods (T < 9215, p < .001). CONCLUSIONS All methods were similarly discordant in their relative accuracy, despite having significant technical differences in their application. The differing protocols and technical aspects of each method, however, have the implication that one may be more practical depending on the clinical or research application at hand.
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Affiliation(s)
- Thomas Tonroe
- Bionics InstituteEast MelbourneVictoriaAustralia
- School of EngineeringRMIT UniversityMelbourneVictoriaAustralia
| | - Hugh McDermott
- Bionics InstituteEast MelbourneVictoriaAustralia
- DBS Technologies Pty LtdEast MelbourneVictoriaAustralia
- Medical Bionics DepartmentThe University of MelbourneEast MelbourneVictoriaAustralia
| | - Patrick Pearce
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of NeurosurgerySt Vincent's Hospital MelbourneFitzroyVictoriaAustralia
| | - Nicola Acevedo
- Bionics InstituteEast MelbourneVictoriaAustralia
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
| | - Wesley Thevathasan
- Bionics InstituteEast MelbourneVictoriaAustralia
- DBS Technologies Pty LtdEast MelbourneVictoriaAustralia
- Department of NeurologyAustin HospitalHeidelbergVictoriaAustralia
- Department of MedicineThe University of MelbourneParkvilleVictoriaAustralia
- Department of NeurologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Department of NeurosurgeryCabrini HospitalMalvernVictoriaAustralia
| | - San San Xu
- Bionics InstituteEast MelbourneVictoriaAustralia
- Medical Bionics DepartmentThe University of MelbourneEast MelbourneVictoriaAustralia
- Department of NeurologyAustin HospitalHeidelbergVictoriaAustralia
| | - Kristian Bulluss
- Bionics InstituteEast MelbourneVictoriaAustralia
- DBS Technologies Pty LtdEast MelbourneVictoriaAustralia
- Department of NeurosurgerySt Vincent's Hospital MelbourneFitzroyVictoriaAustralia
- Department of NeurosurgeryCabrini HospitalMalvernVictoriaAustralia
- Department of NeurosurgeryAustin HospitalHeidelbergVictoriaAustralia
- Department of SurgeryThe University of MelbourneParkvilleVictoriaAustralia
| | - Thushara Perera
- Bionics InstituteEast MelbourneVictoriaAustralia
- DBS Technologies Pty LtdEast MelbourneVictoriaAustralia
- Medical Bionics DepartmentThe University of MelbourneEast MelbourneVictoriaAustralia
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Askari A, Lam JLW, Zhu BJ, Lu CW, Chou KL, Wyant KJ, Patil PG. Dorsal subthalamic deep brain stimulation improves pain in Parkinson's disease. FRONTIERS IN PAIN RESEARCH 2023; 4:1240379. [PMID: 37663307 PMCID: PMC10469498 DOI: 10.3389/fpain.2023.1240379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Inconsistent effects of subthalamic deep brain stimulation (STN DBS) on pain, a common non-motor symptom of Parkinson's disease (PD), may be due to variations in active contact location relative to some pain-reducing locus of stimulation. This study models and compares the loci of maximal effect for pain reduction and motor improvement in STN DBS. Methods We measured Movement Disorder Society Unified PD Rating Scale (MDS-UPDRS) Part I pain score (item-9), and MDS-UPDRS Part III motor score, preoperatively and 6-12 months after STN DBS. An ordinary least-squares regression model was used to examine active contact location as a predictor of follow-up pain score while controlling for baseline pain, age, dopaminergic medication, and motor improvement. An atlas-independent isotropic electric field model was applied to distinguish sites of maximally effective stimulation for pain and motor improvement. Results In 74 PD patients, mean pain score significantly improved after STN DBS (p = 0.01). In a regression model, more dorsal active contact location was the only significant predictor of pain improvement (R2 = 0.17, p = 0.03). The stimulation locus for maximal pain improvement was lateral, anterior, and dorsal to that for maximal motor improvement. Conclusion STN stimulation, dorsal to the site of optimal motor improvement, improves pain. This region contains the zona incerta, which is known to modulate pain in humans, and may explain this observation.
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Affiliation(s)
- Asra Askari
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Jordan L. W. Lam
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Brandon J. Zhu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Charles W. Lu
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Kelvin L. Chou
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Kara J. Wyant
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Parag G. Patil
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
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Rao AT, Chou KL, Patil PG. Localization of deep brain stimulation trajectories via automatic mapping of microelectrode recordings to MRI. J Neural Eng 2023; 20. [PMID: 36763997 DOI: 10.1088/1741-2552/acbb2b] [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: 07/09/2022] [Accepted: 02/10/2023] [Indexed: 02/12/2023]
Abstract
Objective. Suboptimal electrode placement during subthalamic nucleus deep brain stimulation (STN DBS) surgery may arise from several sources, including frame-based targeting errors and intraoperative brain shift. We present a computer algorithm that can accurately localize intraoperative microelectrode recording (MER) tracks on preoperative magnetic resonance imaging (MRI) in real-time, thereby predicting deviation between the surgical plan and the MER trajectories.Approach. Random forest (RF) modeling was used to derive a statistical relationship between electrophysiological features on intraoperative MER and voxel intensity on preoperative T2-weighted MR imaging. This model was integrated into a larger algorithm that can automatically localize intraoperative MER recording tracks on preoperative MRI in real-time. To verify accuracy, targeting error of both the planned intraoperative trajectory ('planned') and the algorithm-derived trajectory ('calculated') was estimated by measuring deviation from the final DBS lead location on postoperative high-resolution computed tomography ('actual').Main results. MR imaging and MERs were obtained from 24 STN DBS implant trajectories. The cross-validated RF model could accurately distinguish between gray and white matter regions along MER trajectories (AUC 0.84). When applying this model within the localization algorithm, thecalculatedMER trajectory estimate was found to be significantly closer to theactualDBS lead when compared to theplannedtrajectory recorded during surgery (1.04 mm vs 1.52 mm deviation,p< 0.002), with improvement shown in 19/24 cases (79%). When applying the algorithm to simulated DBS trajectory plans with randomized targeting error, up to 4 mm of error could be resolved to <2 mm on average (p< 0.0001).Significance. This work presents an automated system for intraoperative localization of electrodes during STN DBS surgery. This neuroengineering solution may enhance the accuracy of electrode position estimation, particularly in cases where high-resolution intraoperative imaging is not available.
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Affiliation(s)
- Akshay T Rao
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | - Kelvin L Chou
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America.,Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America.,Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States of America
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Askari A, Greif TR, Lam J, Maher AC, Persad CC, Patil PG. Decline of verbal fluency with lateral superior frontal gyrus penetration in subthalamic nucleus deep brain stimulation for Parkinson disease. J Neurosurg 2022; 137:729-734. [PMID: 35090137 DOI: 10.3171/2021.11.jns211528] [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: 06/24/2021] [Accepted: 11/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Verbal fluency (VF) decline is a well-recognized adverse cognitive outcome following subthalamic nucleus deep brain stimulation (STN DBS) in patients with Parkinson disease (PD). The mechanisms underlying VF decline, whether from stimulation, lesioning, or both, remain unclear. This study aims to investigate the unique effects of DBS lead trajectory on VF beyond previously reported effects of active contact location. METHODS The study population included 56 patients with idiopathic PD who underwent bilateral STN DBS. Phonemic and semantic VF scores were compared pre- and postoperatively. Features of the electrode trajectory were measured on postoperative imaging, including distance from the falx cerebri, distance from the superior frontal sulcus, and caudate nucleus penetration. The authors used t-tests, Pearson's correlation, and multiple linear regression analyses to examine the relationship between VF change and demographic, disease, and electrode trajectory variables. RESULTS The laterality of entry within the left superior frontal gyrus (SFG) predicted greater phonemic VF decline (sr2 = 0.28, p < 0.001) after controlling for active contact location. VF change did not differ by the presence of caudate nucleus penetration in either hemisphere (p > 0.05). CONCLUSIONS Lateral penetration of the SFG in the left hemisphere is associated with worsening phonemic VF and has greater explanatory power than active contact location. This may be explained by lesioning of the lateral SFG-Broca area pathway, which is implicated in language function.
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Affiliation(s)
| | - Taylor R Greif
- 2Department of Psychiatry-Neuropsychology Section, University of Michigan, Ann Arbor, Michigan
| | | | - Amanda C Maher
- 2Department of Psychiatry-Neuropsychology Section, University of Michigan, Ann Arbor, Michigan
| | - Carol C Persad
- 2Department of Psychiatry-Neuropsychology Section, University of Michigan, Ann Arbor, Michigan
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Kluin KJ, Mossner JM, Costello JT, Chou KL, Patil PG. Motor speech effects in subthalamic deep brain stimulation for Parkinson's disease. J Neurosurg 2022; 137:722-728. [PMID: 35090126 PMCID: PMC10193494 DOI: 10.3171/2021.12.jns211729] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A motor speech disorder or dysarthria commonly arises in patients with Parkinson's disease (PD). The impact of subthalamic nucleus (STN) deep brain stimulation (DBS) on motor speech and the potential of intraoperative motor speech testing to predict outcomes are unknown. This study examined 1) the types and prevalence of motor speech changes observed with STN DBS and their relation to the preoperative condition, 2) the ability of intraoperative testing to predict postoperative changes in motor speech, and 3) the spatial relationship between stimulation sites producing maximal motor improvement, as measured by the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), and maximal motor speech deterioration. METHODS Comprehensive preoperative, intraoperative, and postoperative motor speech/dysarthria evaluations were performed in consecutive patients with advanced idiopathic PD who underwent STN DBS surgery in the period from 2011 to 2016. Preoperative type of dysarthria and overall dysarthria severity rating along with intraoperative motor speech testing results were evaluated as predictors of postoperative change. Atlas-independent, fully individualized field modeling was used to identify stimulation sites associated with maximal MDS-UPDRS motor improvement and motor speech deterioration. RESULTS Forty-three patients with PD treated with STN DBS were prospectively studied. Improved MDS-UPDRS motor scores and worsened dysarthria were demonstrated by a subset of patients (16/43). Preoperative dysarthria characteristics did not predict postoperative deterioration. Intraoperative assessment of motor speech strongly predicted postoperative outcomes (OR 4.4, p = 0.02). Sites of maximal MDS-UPDRS motor improvement and worsened dysarthria were distinct. Worsened dysarthria was associated with capsular stimulation, anterior and ventral to the site of maximal MDS-UPDRS motor improvement. CONCLUSIONS The predictive reliability of intraoperative motor speech testing, together with the identification of distinct stimulation sites for motor speech impairment and improved MDS-UPDRS motor function, raise the possibility that DBS lead repositioning or reprogramming could reduce adverse effects on motor speech without impacting MDS-UPDRS motor outcomes in patients undergoing STN DBS.
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Affiliation(s)
| | | | | | | | - Parag G. Patil
- Neurology
- Neurosurgery
- Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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Sinclair NC, McDermott HJ, Lee WL, Xu SS, Acevedo N, Begg A, Perera T, Thevathasan W, Bulluss KJ. Electrically evoked and spontaneous neural activity in the subthalamic nucleus under general anesthesia. J Neurosurg 2022; 137:449-458. [PMID: 34891136 DOI: 10.3171/2021.8.jns204225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) surgery is commonly performed with the patient awake to facilitate assessments of electrode positioning. However, awake neurosurgery can be a barrier to patients receiving DBS. Electrode implantation can be performed with the patient under general anesthesia (GA) using intraoperative imaging, although such techniques are not widely available. Electrophysiological features can also aid in the identification of target neural regions and provide functional evidence of electrode placement. Here we assess the presence and positional variation under GA of spontaneous beta and high-frequency oscillation (HFO) activity, and evoked resonant neural activity (ERNA), a novel evoked response localized to the subthalamic nucleus. METHODS ERNA, beta, and HFO were intraoperatively recorded from DBS leads comprising four individual electrodes immediately after bilateral awake implantation into the subthalamic nucleus of 21 patients with Parkinson's disease (42 hemispheres) and after subsequent GA induction deep enough to perform pulse generator implantation. The main anesthetic agent was either propofol (10 patients) or sevoflurane (11 patients). RESULTS GA reduced the amplitude of ERNA, beta, and HFO activity (p < 0.001); however, ERNA amplitudes remained large in comparison to spontaneous local field potentials. Notably, a moderately strong correlation between awake ERNA amplitude and electrode distance to an "ideal" therapeutic target within dorsal STN was preserved under GA (awake: ρ = -0.73, adjusted p value [padj] < 0.001; GA: ρ = -0.69, padj < 0.001). In contrast, correlations were diminished under GA for beta (awake: ρ = -0.45, padj < 0.001; GA: ρ = -0.13, padj = 0.12) and HFO (awake: ρ = -0.69, padj < 0.001; GA: ρ = -0.33, padj < 0.001). The largest ERNA occurred at the same electrode (awake vs GA) for 35/42 hemispheres (83.3%) and corresponded closely to the electrode selected by the clinician for chronic therapy at 12 months (awake ERNA 77.5%, GA ERNA 82.5%). The largest beta amplitude occurred at the same electrode (awake vs GA) for only 17/42 (40.5%) hemispheres and 21/42 (50%) for HFO. The electrode measuring the largest awake beta and HFO amplitudes corresponded to the electrode selected by the clinician for chronic therapy at 12 months in 60% and 70% of hemispheres, respectively. However, this correspondence diminished substantially under GA (beta 20%, HFO 35%). CONCLUSIONS ERNA is a robust electrophysiological signal localized to the dorsal subthalamic nucleus subregion that is largely preserved under GA, indicating it could feasibly guide electrode implantation, either alone or in complementary use with existing methods.
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Affiliation(s)
- Nicholas C Sinclair
- 1Bionics Institute, East Melbourne
- 2Medical Bionics Department, The University of Melbourne, East Melbourne
| | - Hugh J McDermott
- 1Bionics Institute, East Melbourne
- 2Medical Bionics Department, The University of Melbourne, East Melbourne
| | | | - San San Xu
- 1Bionics Institute, East Melbourne
- 3Department of Neurology, Austin Hospital, Heidelberg
| | | | | | - Thushara Perera
- 1Bionics Institute, East Melbourne
- 2Medical Bionics Department, The University of Melbourne, East Melbourne
| | - Wesley Thevathasan
- 1Bionics Institute, East Melbourne
- 3Department of Neurology, Austin Hospital, Heidelberg
- 5Department of Medicine, The University of Melbourne, Parkville
| | - Kristian J Bulluss
- 1Bionics Institute, East Melbourne
- 6Department of Neurosurgery, St. Vincent's and Austin Hospitals, Melbourne; and
- 7Department of Surgery, The University of Melbourne, Heidelberg, Victoria, Australia
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Rao AT, Lu CW, Askari A, Malaga KA, Chou KL, Patil PG. Clinically-derived oscillatory biomarker predicts optimal subthalamic stimulation for Parkinson's disease. J Neural Eng 2022; 19. [PMID: 35272281 DOI: 10.1088/1741-2552/ac5c8c] [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: 01/10/2022] [Accepted: 03/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Choosing the optimal electrode trajectory, stimulation location, and stimulation amplitude in subthalamic nucleus deep brain stimulation (STN DBS) for Parkinson's disease (PD) remains a time-consuming empirical effort. In this retrospective study, we derive a data-driven electrophysiological biomarker that predicts clinical DBS location and parameters, and we consolidate this information into a quantitative score that may facilitate an objective approach to STN DBS surgery and programming. APPROACH Random-forest feature selection was applied to a dataset of 1046 microelectrode recordings sites across 20 DBS implant trajectories to identify features of oscillatory activity that predict clinically programmed volumes of tissue activation (VTA). A cross-validated classifier was used to retrospectively predict VTA regions from these features. Spatial convolution of probabilistic classifier outputs along MER trajectories produced a biomarker score that reflects the probability of localization within a clinically optimized VTA. MAIN RESULTS Biomarker scores peaked within the VTA region and were significantly correlated with percent improvement in postoperative motor symptoms (MDS-UPRDS Part III, R = 0.61, p = 0.004). Notably, the length of STN, a common criterion for trajectory selection, did not show similar correlation (R = -0.31, p = 0.18). These findings suggest that biomarker-based trajectory selection and programming may improve motor outcomes by 9 ± 3 percentage points (p = 0.047) in this dataset. SIGNIFICANCE A clinically defined electrophysiological biomarker not only predicts VTA size and location but also correlates well with motor outcomes. Use of this biomarker for trajectory selection and initial stimulation may potentially simplify STN DBS surgery and programming.
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Affiliation(s)
- Akshay T Rao
- Biomedical Engineering, University of Michigan, 1500 East Medical Center Dr., SPC 5338, Ann Arbor, Michigan, 48109-5338, UNITED STATES
| | - Charles W Lu
- Biomedical Engineering, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, Michigan, 48109-5338, UNITED STATES
| | - Asra Askari
- Biomedical Engineering, University of Michigan, 1500 E Medical Center Drive, SPC 5338, Ann Arbor, Ann Arbor, Michigan, 48109-5338, UNITED STATES
| | - Karlo A Malaga
- Biomedical Engineering, Bucknell University, 316 Academic East Building, Lewisburg, Pennsylvania, 17837, UNITED STATES
| | - Kelvin L Chou
- Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, Michigan, 48109-5338, UNITED STATES
| | - Parag G Patil
- Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, Michigan, 48109-5338, UNITED STATES
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Askari A, Zhu BJ, Lyu X, Chou KL, Patil PG. Characterization and localization of upper and lower extremity motor improvements in STN DBS for Parkinson's disease. Parkinsonism Relat Disord 2021; 94:84-88. [PMID: 34896928 DOI: 10.1016/j.parkreldis.2021.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 11/02/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Subthalamic deep brain stimulation (STN DBS) may have differential effects on cardinal motor signs of Parkinson's disease (PD) in the upper and lower extremities. In addition, sites of maximally effective DBS for each sign and extremity may be distinct. Our study seeks to elucidate these structure-function relationships. METHODS We applied an ordinary least squares linear regression model to measure motor effects of STN DBS on upper (UE) and lower (LE) extremity tremor, rigidity, and bradykinesia. We then applied an atlas-independent electrical-field model to identify sites of maximally effective stimulation for each sign and each extremity. Distances between sites and statistical power to resolve differences were calculated. RESULTS In our study population (n = 78 patients), STN DBS improved all cardinal motor signs (β = 0.64, p < .05). Improvement magnitudes were tremor > rigidity > bradykinesia. Effects of STN DBS on UE versus LE signs were statistically equal for tremor and bradykinesia, but greater for UE rigidity than LE rigidity (β = 0.19, p < .05). UE maximal-effect loci were lateral, anterior, and dorsal to LE loci, but were not statistically resolved, despite sufficient statistical power to resolve differences of ≤0.48 mm (p < .05) between maximally effective loci of stimulation. CONCLUSION STN DBS produces differential effects on UE and LE rigidity, but not for tremor or bradykinesia. This finding is not explained by distinct UE and LE loci of maximally effective stimulation. Instead, we hypothesize that downstream effects of STN DBS on motor networks and limb biomechanics are responsible for observed differences in UE and LE responses.
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Affiliation(s)
- Asra Askari
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Brandon J Zhu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Xiru Lyu
- Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Kelvin L Chou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
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Pearce P, Bulluss K, Xu SS, Kim B, Milicevic M, Perera T, Thevathasan W. How accurately are subthalamic nucleus electrodes implanted relative to the ideal stimulation location for Parkinson's disease? PLoS One 2021; 16:e0254504. [PMID: 34264988 PMCID: PMC8282046 DOI: 10.1371/journal.pone.0254504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 06/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The efficacy of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) depends on how closely electrodes are implanted relative to an individual's ideal stimulation location. Yet, previous studies have assessed how closely electrodes are implanted relative to the planned location, after homogenizing data to a reference. Thus here, we measured how accurately electrodes are implanted relative to an ideal, dorsal STN stimulation location, assessed on each individual's native imaging. This measure captures not only the technical error of stereotactic implantation but also constraints imposed by planning a suitable trajectory. METHODS This cross-sectional study assessed 226 electrodes in 113 consecutive PD patients implanted with bilateral STN-DBS by experienced clinicians utilizing awake, microelectrode guided, surgery. The error (Euclidean distance) between the actual electrode trajectory versus a nominated ideal, dorsal STN stimulation location was determined in each hemisphere on native imaging and predictive factors sought. RESULTS The median electrode location error was 1.62 mm (IQR = 1.23 mm). This error exceeded 3 mm in 28/226 electrodes (12.4%). Location error did not differ between hemispheres implanted first or second, suggesting brain shift was minimised. Location error did not differ between electrodes positioned with (48/226), or without, a preceding microelectrode trajectory shift (suggesting such shifts were beneficial). There was no relationship between location error and case order, arguing against a learning effect. DISCUSSION/CONCLUSION The proximity of STN-DBS electrodes to a nominated ideal, dorsal STN, stimulation location is highly variable, even when implanted by experienced clinicians with brain shift minimized, and without evidence of a learning effect. Using this measure, we found that assessments on awake patients (microelectrode recordings and clinical examination) likely yielded beneficial intraoperative decisions to improve positioning. In many patients the error is likely to have reduced therapeutic efficacy. More accurate methods to implant STN-DBS electrodes relative to the ideal stimulation location are needed.
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Affiliation(s)
- Patrick Pearce
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Kristian Bulluss
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Neurosurgery, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - San San Xu
- Bionics Institute, East Melbourne, Victoria, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, Victoria, Australia
- Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Boaz Kim
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
| | | | - Thushara Perera
- Bionics Institute, East Melbourne, Victoria, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, Victoria, Australia
| | - Wesley Thevathasan
- Bionics Institute, East Melbourne, Victoria, Australia
- Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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11
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Lu CW, Harper DE, Askari A, Willsey MS, Vu PP, Schrepf AD, Harte SE, Patil PG. Stimulation of zona incerta selectively modulates pain in humans. Sci Rep 2021; 11:8924. [PMID: 33903611 PMCID: PMC8076305 DOI: 10.1038/s41598-021-87873-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 04/06/2021] [Indexed: 12/02/2022] Open
Abstract
Stimulation of zona incerta in rodent models has been shown to modulate behavioral reactions to noxious stimuli. Sensory changes observed in Parkinsonian patients with subthalamic deep brain stimulation suggest that this effect is translatable to humans. Here, we utilized the serendipitous placement of subthalamic deep brain stimulation leads in 6 + 5 Parkinsonian patients to directly investigate the effects of zona incerta stimulation on human pain perception. We found that stimulation at 20 Hz, the physiological firing frequency of zona incerta, reduces experimental heat pain by a modest but significant amount, achieving a 30% reduction in one fifth of implants. Stimulation at higher frequencies did not modulate heat pain. Modulation was selective for heat pain and was not observed for warmth perception or pressure pain. These findings provide a mechanistic explanation of sensory changes seen in subthalamic deep brain stimulation patients and identify zona incerta as a potential target for neuromodulation of pain.
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Affiliation(s)
- Charles W Lu
- Department of Neurosurgery, University of Michigan, 1500 E Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Daniel E Harper
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Asra Askari
- Department of Neurosurgery, University of Michigan, 1500 E Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA
| | - Matthew S Willsey
- Department of Neurosurgery, University of Michigan, 1500 E Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Philip P Vu
- Department of Neurosurgery, University of Michigan, 1500 E Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Andrew D Schrepf
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Steven E Harte
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, USA.,Division of Rheumatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Neurosurgery, University of Michigan, 1500 E Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA. .,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
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12
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Malaga KA, Costello JT, Chou KL, Patil PG. Atlas-independent, N-of-1 tissue activation modeling to map optimal regions of subthalamic deep brain stimulation for Parkinson disease. NEUROIMAGE-CLINICAL 2020; 29:102518. [PMID: 33333464 PMCID: PMC7736726 DOI: 10.1016/j.nicl.2020.102518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 01/13/2023]
Abstract
Neuroanatomical variations among patients are obscured in atlas-based VTA modeling. N-of-1 neuroanatomical and VTA modeling enables patient-level precision. Mean optimal stimulation is dorsomedial to the STN, near its posterior half. Individual VTAs deviate from optimal stimulation sites to varying degrees. Optimal stimulation sites for rigidity, bradykinesia, and tremor partially overlap.
Background Motor outcomes after subthalamic deep brain stimulation (STN DBS) for Parkinson disease (PD) vary considerably among patients and strongly depend on stimulation location. The objective of this retrospective study was to map the regions of optimal STN DBS for PD using an atlas-independent, fully individualized (N-of-1) tissue activation modeling approach and to assess the relationship between patient-level therapeutic volumes of tissue activation (VTAs) and motor improvement. Methods The stimulation-induced electric field for 40 PD patients treated with bilateral STN DBS was modeled using finite element analysis. Neurostimulation models were generated for each patient, incorporating their individual STN anatomy, DBS lead position and orientation, anisotropic tissue conductivity, and clinical stimulation settings. A voxel-based analysis of the VTAs was then used to map the optimal location of stimulation. The amount of stimulation in specific regions relative to the STN was measured and compared between STNs with more and less optimal stimulation, as determined by their motor improvement scores and VTA. The relationship between VTA location and motor outcome was then assessed using correlation analysis. Patient variability in terms of STN anatomy, active contact position, and VTA location were also evaluated. Results from the N-of-1 model were compared to those from a simplified VTA model. Results Tissue activation modeling mapped the optimal location of stimulation to regions medial, posterior, and dorsal to the STN centroid. These regions extended beyond the STN boundary towards the caudal zona incerta (cZI). The location of the VTA and active contact position differed significantly between STNs with more and less optimal stimulation in the dorsal-ventral and anterior-posterior directions. Therapeutic stimulation spread noticeably more in the dorsal and posterior directions, providing additional evidence for cZI as an important DBS target. There were significant linear relationships between the amount of dorsal and posterior stimulation, as measured by the VTA, and motor improvement. These relationships were more robust than those between active contact position and motor improvement. There was high variability in STN anatomy, active contact position, and VTA location among patients. Spherical VTA modeling was unable to reproduce these results and tended to overestimate the size of the VTA. Conclusion Accurate characterization of the spread of stimulation is needed to optimize STN DBS for PD. High variability in neuroanatomy, stimulation location, and motor improvement among patients highlights the need for individualized modeling techniques. The atlas-independent, N-of-1 tissue activation modeling approach presented in this study can be used to develop and evaluate stimulation strategies to improve clinical outcomes on an individual basis.
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Affiliation(s)
- Karlo A Malaga
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Joseph T Costello
- Department of Electrical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Kelvin L Chou
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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13
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Mossner JM, Chou KL, Maher AH, Persad CC, Patil PG. Localization of motor and verbal fluency effects in subthalamic DBS for Parkinson's disease. Parkinsonism Relat Disord 2020; 79:55-59. [PMID: 32866879 DOI: 10.1016/j.parkreldis.2020.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Subthalamic nucleus deep brain stimulation (STN DBS) improves cardinal motor symptoms of Parkinson's disease (PD) but can worsen verbal fluency (VF). An optimal site of stimulation for overall motor improvement has been previously identified using an atlas-independent, fully individualized, field-modeling approach. This study examines if cardinal motor components (bradykinesia, tremor, and rigidity) share this identified optimal improvement site and if there is co-localization with a site that worsens VF. METHODS An atlas-independent, field-modeling approach was used to identify sites of maximal STN DBS effect on overall and cardinal motor symptoms and VF in 60 patients. Anatomic coordinates were referenced to the STN midpoint. Symptom severity was assessed with the MDS-UPDRS part III and established VF scales. RESULTS Sites for improved bradykinesia and rigidity co-localized with each other and the overall part III site (0.09 mm lateral, 0.93 mm posterior, 1.75 mm dorsal). The optimal site for tremor was posterior to this site (0.10 mm lateral, 1.40 mm posterior, 1.93 mm dorsal). Semantic and phonemic VF sites were indistinguishable and co-localized medial to the motor sites (0.32 mm medial, 1.18 mm posterior, 1.74 mm dorsal). CONCLUSION This study identifies statistically distinct, maximally effective stimulation sites for tremor improvement, VF worsening, and overall and other cardinal motor improvements in STN DBS. Current electrode sizes and voltage settings stimulate all of these sites simultaneously. However, future targeted lead placement and focused directional stimulation may avoid VF worsening while maintaining motor improvements in STN DBS.
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Affiliation(s)
- James M Mossner
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Kelvin L Chou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Amanda H Maher
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Carol C Persad
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
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14
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Xiao Y, Lau JC, Hemachandra D, Gilmore G, Khan AR, Peters TM. Image Guidance in Deep Brain Stimulation Surgery to Treat Parkinson's Disease: A Comprehensive Review. IEEE Trans Biomed Eng 2020; 68:1024-1033. [PMID: 32746050 DOI: 10.1109/tbme.2020.3006765] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Deep brain stimulation (DBS) is an effective therapy as an alternative to pharmaceutical treatments for Parkinson's disease (PD). Aside from factors such as instrumentation, treatment plans, and surgical protocols, the success of the procedure depends heavily on the accurate placement of the electrode within the optimal therapeutic targets while avoiding vital structures that can cause surgical complications and adverse neurologic effects. Although specific surgical techniques for DBS can vary, interventional guidance with medical imaging has greatly contributed to the development, outcomes, and safety of the procedure. With rapid development in novel imaging techniques, computational methods, and surgical navigation software, as well as growing insights into the disease and mechanism of action of DBS, modern image guidance is expected to further enhance the capacity and efficacy of the procedure in treating PD. This article surveys the state-of-the-art techniques in image-guided DBS surgery to treat PD, and discusses their benefits and drawbacks, as well as future directions on the topic.
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15
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Lu CW, Malaga KA, Chou KL, Chestek CA, Patil PG. High density microelectrode recording predicts span of therapeutic tissue activation volumes in subthalamic deep brain stimulation for Parkinson disease. Brain Stimul 2020; 13:412-419. [DOI: 10.1016/j.brs.2019.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 01/16/2023] Open
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16
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Dodani SS, Lu CW, Aldridge JW, Chou KL, Patil PG. A Computerized Microelectrode Recording to Magnetic Resonance Imaging Mapping System for Subthalamic Nucleus Deep Brain Stimulation Surgery. Oper Neurosurg (Hagerstown) 2019; 14:661-667. [PMID: 28961898 DOI: 10.1093/ons/opx169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 07/11/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Accurate electrode placement is critical to the success of deep brain stimulation (DBS) surgery. Suboptimal targeting may arise from poor initial target localization, frame-based targeting error, or intraoperative brain shift. These uncertainties can make DBS surgery challenging. OBJECTIVE To develop a computerized system to guide subthalamic nucleus (STN) DBS electrode localization and to estimate the trajectory of intraoperative microelectrode recording (MER) on magnetic resonance (MR) images algorithmically during DBS surgery. METHODS Our method is based upon the relationship between the high-frequency band (HFB; 500-2000 Hz) signal from MER and voxel intensity on MR images. The HFB profile along an MER trajectory recorded during surgery is compared to voxel intensity profiles along many potential trajectories in the region of the surgically planned trajectory. From these comparisons of HFB recordings and potential trajectories, an estimate of the MER trajectory is calculated. This calculated trajectory is then compared to actual trajectory, as estimated by postoperative high-resolution computed tomography. RESULTS We compared 20 planned, calculated, and actual trajectories in 13 patients who underwent STN DBS surgery. Targeting errors for our calculated trajectories (2.33 mm ± 0.2 mm) were significantly less than errors for surgically planned trajectories (2.83 mm ± 0.2 mm; P = .01), improving targeting prediction in 70% of individual cases (14/20). Moreover, in 4 of 4 initial MER trajectories that missed the STN, our method correctly indicated the required direction of targeting adjustment for the DBS lead to intersect the STN. CONCLUSION A computer-based algorithm simultaneously utilizing MER and MR information potentially eases electrode localization during STN DBS surgery.
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Affiliation(s)
- Sunjay S Dodani
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, Michigan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Charles W Lu
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, Michigan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - J Wayne Aldridge
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, Michigan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Psychology, University of Michigan, Ann Arbor, Michigan
| | - Kelvin L Chou
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, Michigan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Parag G Patil
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, Michigan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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17
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Lemaire JJ, De Salles A, Coll G, El Ouadih Y, Chaix R, Coste J, Durif F, Makris N, Kikinis R. MRI Atlas of the Human Deep Brain. Front Neurol 2019; 10:851. [PMID: 31507507 PMCID: PMC6718608 DOI: 10.3389/fneur.2019.00851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/23/2019] [Indexed: 12/15/2022] Open
Abstract
Mastering detailed anatomy of the human deep brain in clinical neurosciences is challenging. Although numerous pioneering works have gathered a large dataset of structural and topographic information, it is still difficult to transfer this knowledge into practice, even with advanced magnetic resonance imaging techniques. Thus, classical histological atlases continue to be used to identify structures for stereotactic targeting in functional neurosurgery. Physicians mainly use these atlases as a template co-registered with the patient's brain. However, it is possible to directly identify stereotactic targets on MRI scans, enabling personalized targeting. In order to help clinicians directly identify deep brain structures relevant to present and future medical applications, we built a volumetric MRI atlas of the deep brain (MDBA) on a large scale (infra millimetric). Twelve hypothalamic, 39 subthalamic, 36 telencephalic, and 32 thalamic structures were identified, contoured, and labeled. Nineteen coronal, 18 axial, and 15 sagittal MRI plates were created. Although primarily designed for direct labeling, the anatomic space was also subdivided in twelfths of AC-PC distance, leading to proportional scaling in the coronal, axial, and sagittal planes. This extensive work is now available to clinicians and neuroscientists, offering another representation of the human deep brain ([https://hal.archives-ouvertes.fr/] [hal-02116633]). The atlas may also be used by computer scientists who are interested in deciphering the topography of this complex region.
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Affiliation(s)
- Jean-Jacques Lemaire
- Service de Neurochirurgie, CHU Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Engineering School SIGMA Clermont, Clermont-Ferrand, France
| | - Antonio De Salles
- Department of Neurosurgery, Radiation Oncology, HCOR Neuroscience, São Paulo, Brazil
| | - Guillaume Coll
- Service de Neurochirurgie, CHU Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Engineering School SIGMA Clermont, Clermont-Ferrand, France
| | - Youssef El Ouadih
- Service de Neurochirurgie, CHU Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Engineering School SIGMA Clermont, Clermont-Ferrand, France
| | - Rémi Chaix
- Service de Neurochirurgie, CHU Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Engineering School SIGMA Clermont, Clermont-Ferrand, France
| | - Jérôme Coste
- Service de Neurochirurgie, CHU Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Engineering School SIGMA Clermont, Clermont-Ferrand, France
| | - Franck Durif
- Service de Neurologie, Centre National de la Recherche Scientifique, CHU Clermont-Ferrand, Université Clermont Auvergne, Engineering School SIGMA Clermont, Clermont-Ferrand, France
| | - Nikos Makris
- Surgical Planning Laboratory, Center for Morphometric Analysis, A. Martinos Center for Biomedical Imaging, Harvard Medical School, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, MA, United States
| | - Ron Kikinis
- Surgical Planning Laboratory, Center for Morphometric Analysis, A. Martinos Center for Biomedical Imaging, Harvard Medical School, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, MA, United States.,Robert Greenes Distinguished Director of Biomedical Informatics, Brigham and Women's Hospital, Boston, MA, United States.,Computer Science Department, Fraunhofer MEVIS, University of Bremen, Bremen, Germany
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18
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Koivu M, Huotarinen A, Scheperjans F, Laakso A, Kivisaari R, Pekkonen E. Motor outcome and electrode location in deep brain stimulation in Parkinson's disease. Brain Behav 2018; 8:e01003. [PMID: 29851316 PMCID: PMC6043715 DOI: 10.1002/brb3.1003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/16/2018] [Accepted: 04/15/2018] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To evaluate the efficacy and adverse effects of subthalamic deep brain stimulation (STN-DBS) in patients with advanced Parkinson's disease (PD) and the possible correlation between electrode location and clinical outcome. METHODS We retrospectively reviewed 87 PD-related STN-DBS operations at Helsinki University Hospital (HUH) from 2007 to 2014. The changes of Unified Parkinson's Disease Rating Scale (UPDRS) part III score, Hoehn & Yahr stage, antiparkinson medication, and adverse effects were studied. We estimated the active electrode location in three different coordinate systems: direct visual analysis of MRI correlated to brain atlas, location in relation to the nucleus borders and location in relation to the midcommisural point. RESULTS At 6 months after operation, both levodopa equivalent doses (LEDs; 35%, Wilcoxon signed-rank test = 0.000) and UPDRS part III scores significantly decreased (38%, Wilcoxon signed-rank test = 0.000). Four patients (5%) suffered from moderate DBS-related dysarthria. The generator and electrodes had to be removed in one patient due to infection (1%). Electrode coordinates in the three coordinate systems correlated well with each other. On the left side, more ventral location of the active contact was associated with greater LED decrease. CONCLUSIONS STN-DBS improves motor function and enables the reduction in antiparkinson medication with an acceptable adverse effect profile. More ventral location of the active contact may allow stronger LED reduction. Further research on the correlation between contact location, clinical outcome, and LED reduction is warranted.
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Affiliation(s)
- Maija Koivu
- Department of Neurology, Meilahti Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Antti Huotarinen
- Department of Neurosurgery, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Filip Scheperjans
- Department of Neurology, Meilahti Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Eero Pekkonen
- Department of Neurology, Meilahti Hospital, Helsinki University Hospital, Helsinki, Finland
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19
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Conrad E, Mossner J, Chou K, Patil P. Atlas-Independent, Electrophysiological Mapping of the Optimal Locus of Subthalamic Deep Brain Stimulation for the Motor Symptoms of Parkinson Disease. Stereotact Funct Neurosurg 2018; 96:91-99. [DOI: 10.1159/000486643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
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20
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Sinclair NC, McDermott HJ, Bulluss KJ, Fallon JB, Perera T, Xu SS, Brown P, Thevathasan W. Subthalamic nucleus deep brain stimulation evokes resonant neural activity. Ann Neurol 2018; 83:1027-1031. [PMID: 29727475 PMCID: PMC6025792 DOI: 10.1002/ana.25234] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 11/27/2022]
Abstract
Deep brain stimulation (DBS) is a rapidly expanding treatment for neurological and psychiatric conditions; however, a target-specific biomarker is required to optimize therapy. Here, we show that DBS evokes a large-amplitude resonant neural response focally in the subthalamic nucleus. This response is greatest in the dorsal region (the clinically optimal stimulation target for Parkinson disease), coincides with improved clinical performance, is chronically recordable, and is present under general anesthesia. These features make it a readily utilizable electrophysiological signal that could potentially be used for guiding electrode implantation surgery and tailoring DBS therapy to improve patient outcomes.
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Affiliation(s)
- Nicholas C Sinclair
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Medical Bionics, University of Melbourne, East Melbourne, Victoria, Australia
| | - Hugh J McDermott
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Medical Bionics, University of Melbourne, East Melbourne, Victoria, Australia
| | - Kristian J Bulluss
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Neurosurgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Neurosurgery, Austin Hospital, Heidelberg, Victoria, Australia
| | - James B Fallon
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Medical Bionics, University of Melbourne, East Melbourne, Victoria, Australia
| | - Thushara Perera
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Medical Bionics, University of Melbourne, East Melbourne, Victoria, Australia
| | - San San Xu
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Medical Bionics, University of Melbourne, East Melbourne, Victoria, Australia.,Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Peter Brown
- Medical Research Council Brain Network Dynamics Unit and Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Wesley Thevathasan
- Bionics Institute, East Melbourne, Victoria, Australia.,Department of Neurology, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Australia
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21
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Tamir I, Marmor-Levin O, Eitan R, Bergman H, Israel Z. Posterolateral Trajectories Favor a Longer Motor Domain in Subthalamic Nucleus Deep Brain Stimulation for Parkinson Disease. World Neurosurg 2017; 106:450-461. [DOI: 10.1016/j.wneu.2017.06.178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 01/08/2023]
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22
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Bentley JN, Guan Z, Cummings KS, Chou KL, Patil PG. Influence of Intracranial Air on Electrode Position and Clinical Outcomes following Deep Brain Stimulation for Parkinson's Disease. Stereotact Funct Neurosurg 2017; 95:6-12. [DOI: 10.1159/000452843] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 10/18/2016] [Indexed: 11/19/2022]
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23
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Lau JC, Khan AR, Zeng TY, MacDougall KW, Parrent AG, Peters TM. Quantification of local geometric distortion in structural magnetic resonance images: Application to ultra-high fields. Neuroimage 2017; 168:141-151. [PMID: 28069539 DOI: 10.1016/j.neuroimage.2016.12.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 12/13/2022] Open
Abstract
Ultra-high field magnetic resonance imaging (MRI) provides superior visualization of brain structures compared to lower fields, but images may be prone to severe geometric inhomogeneity. We propose to quantify local geometric distortion at ultra-high fields in in vivo datasets of human subjects scanned at both ultra-high field and lower fields. By using the displacement field derived from nonlinear image registration between images of the same subject, focal areas of spatial uncertainty are quantified. Through group and subject-specific analysis, we were able to identify regions systematically affected by geometric distortion at air-tissue interfaces prone to magnetic susceptibility, where the gradient coil non-linearity occurs in the occipital and suboccipital regions, as well as with distance from image isocenter. The derived displacement maps, quantified in millimeters, can be used to prospectively evaluate subject-specific local spatial uncertainty that should be taken into account in neuroimaging studies, and also for clinical applications like stereotactic neurosurgery where accuracy is critical. Validation with manual fiducial displacement demonstrated excellent correlation and agreement. Our results point to the need for site-specific calibration of geometric inhomogeneity. Our methodology provides a framework to permit prospective evaluation of the effect of MRI sequences, distortion correction techniques, and scanner hardware/software upgrades on geometric distortion.
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Affiliation(s)
- Jonathan C Lau
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada; Biomedical Engineering Graduate Program, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University and London Health Sciences Centre, London, Ontario, Canada.
| | - Ali R Khan
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada; Biomedical Engineering Graduate Program, Western University, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Tony Y Zeng
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada
| | - Keith W MacDougall
- Department of Clinical Neurological Sciences, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Andrew G Parrent
- Department of Clinical Neurological Sciences, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Terry M Peters
- Imaging Research Laboratories, Robarts Research Institute, London, Ontario, Canada; Biomedical Engineering Graduate Program, Western University, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada
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24
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Rabie A, Verhagen Metman L, Slavin KV. Using "Functional" Target Coordinates of the Subthalamic Nucleus to Assess the Indirect and Direct Methods of the Preoperative Planning: Do the Anatomical and Functional Targets Coincide? Brain Sci 2016; 6:brainsci6040065. [PMID: 28009826 PMCID: PMC5187579 DOI: 10.3390/brainsci6040065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/04/2016] [Accepted: 12/12/2016] [Indexed: 11/16/2022] Open
Abstract
Objective: To answer the question of whether the anatomical center of the subthalamic nucleus (STN), as calculated indirectly from stereotactic atlases or by direct visualization on magnetic resonance imaging (MRI), corresponds to the best functional target. Since the neighboring red nucleus (RN) is well visualized on MRI, we studied the relationships of the final target to its different borders. Methods: We analyzed the data of 23 PD patients (46 targets) who underwent bilateral frame-based STN deep brain stimulation (DBS) procedure with microelectrode recording guidance. We calculated coordinates of the active contact on DBS electrode on postoperative MRI, which we referred to as the final “functional/optimal” target. The coordinates calculated by the atlas-based “indirect” and “direct” methods, as well as the coordinates of the different RN borders were compared to these final coordinates. Results: The mean ± SD of the final target coordinates was 11.7 ± 1.5 mm lateral (X), 2.4 ± 1.5 mm posterior (Y), and 6.1 ± 1.7 mm inferior to the mid-commissural point (Z). No significant differences were found between the “indirect” X, Z coordinates and those of the final targets. The “indirect” Y coordinate was significantly posterior to Y of the final target, with mean difference of 0.6 mm (p = 0.014). No significant differences were found between the “direct” X, Y, and Z coordinates and those of the final targets. Conclusions: The functional STN target is located in direct proximity to its anatomical center. During preoperative targeting, we recommend using the “direct” method, and taking into consideration the relationships of the final target to the mid-commissural point (MCP) and the different RN borders.
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Affiliation(s)
- Ahmed Rabie
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt.
| | - Leo Verhagen Metman
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612, USA.
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Verhagen R, Schuurman PR, van den Munckhof P, Contarino MF, de Bie RMA, Bour LJ. Comparative study of microelectrode recording-based STN location and MRI-based STN location in low to ultra-high field (7.0 T) T2-weighted MRI images. J Neural Eng 2016; 13:066009. [DOI: 10.1088/1741-2560/13/6/066009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Zwirner J, Möbius D, Bechmann I, Arendt T, Hoffmann KT, Jäger C, Lobsien D, Möbius R, Planitzer U, Winkler D, Morawski M, Hammer N. Subthalamic nucleus volumes are highly consistent but decrease age-dependently-a combined magnetic resonance imaging and stereology approach in humans. Hum Brain Mapp 2016; 38:909-922. [PMID: 27726278 DOI: 10.1002/hbm.23427] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 09/08/2016] [Accepted: 09/26/2016] [Indexed: 01/03/2023] Open
Abstract
The subthalamic nucleus (STN) is a main target structure of deep brain stimulation (DBS) in idiopathic Parkinson's disease. Nevertheless, there is an ongoing discussion regarding human STN volumes and neuron count, which could potentially have an impact on STN-DBS. Moreover, a suspected functional subdivision forms the basis of the tripartite hypothesis, which has not yet been morphologically substantiated. In this study, it was aimed to investigate the human STN by means of combined magnetic resonance imaging (MRI) and stereology. STN volumes were obtained from 14 individuals (ranging from 65 to 96 years, 25 hemispheres) in 3 T MRI and in luxol-stained histology slices. Neuron number and cell densities were investigated stereologically over the entire STN and in pre-defined subregions in anti-human neuronal protein HuC/D-stained slices. STN volumes measured with MRI were smaller than in stereology but appeared to be highly consistent, measuring on average 99 ± 6 mm3 (MRI) and 132 ± 20 mm3 (stereology). The neuron count was 431,088 ± 72,172. Both STN volumes and cell count decreased age-dependently. Neuron density was different for the dorsal, medial and ventral subregion with significantly higher values ventrally than dorsally. Small variations in STN volumes in both MRI and stereology contradict previous findings of large variations in STN size. Age-dependent decreases in STN volumes and neuron numbers might influence the efficacy of STN-DBS in a geriatric population. Though the study is limited in sample size, site-dependent differences for the STN subregions form a morphological basis for the tripartite theory. Hum Brain Mapp 38:909-922, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Johann Zwirner
- Faculty of Medicine, Institute of Anatomy University of Leipzig, Leipzig, Germany
| | - Dustin Möbius
- Faculty of Medicine, Institute of Anatomy University of Leipzig, Leipzig, Germany
| | - Ingo Bechmann
- Faculty of Medicine, Institute of Anatomy University of Leipzig, Leipzig, Germany
| | - Thomas Arendt
- Paul-Flechsig-Institute for Brain Research University of Leipzig, Leipzig, Germany
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, University Clinic of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Carsten Jäger
- Paul-Flechsig-Institute for Brain Research University of Leipzig, Leipzig, Germany
| | - Donald Lobsien
- Department of Neuroradiology, University Clinic of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Robert Möbius
- Faculty of Medicine, Institute of Anatomy University of Leipzig, Leipzig, Germany
| | - Uwe Planitzer
- Department of Neurosurgery, University Clinic of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Dirk Winkler
- Department of Neurosurgery, University Clinic of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Markus Morawski
- Paul-Flechsig-Institute for Brain Research University of Leipzig, Leipzig, Germany
| | - Niels Hammer
- Faculty of Medicine, Institute of Anatomy University of Leipzig, Leipzig, Germany.,Department of Anatomy, University of Otago, Dunedin, New Zealand
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