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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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Holewijn RA, Zoon TJC, Verbaan D, Bergfeld IO, Verwijk E, Geurtsen GJ, van Rooijen G, van den Munckhof P, Bot M, Denys DAJP, De Bie RMA, Schuurman PR. Cognitive and psychiatric outcomes in the GALAXY trial: effect of anaesthesia in deep brain stimulation. J Neurol Neurosurg Psychiatry 2024; 95:214-221. [PMID: 37679030 DOI: 10.1136/jnnp-2023-331791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND This study aims: (1) To compare cognitive and psychiatric outcomes after bilateral awake versus asleep subthalamic nucleus (STN) deep brain stimulation (DBS) surgery for Parkinson's disease (PD). (2) To explore the occurrence of psychiatric diagnoses, cognitive impairment and quality of life after surgery in our whole sample. (3) To validate whether we can predict postoperative cognitive decline. METHODS 110 patients with PD were randomised to receive awake (n=56) or asleep (n=54) STN DBS surgery. At baseline and 6-month follow-up, all patients underwent standardised assessments testing several cognitive domains, psychiatric symptoms and quality of life. RESULTS There were no differences on neuropsychological composite scores and psychiatric symptoms between the groups, but we found small differences on individual tests and cognitive domains. The asleep group performed better on the Rey Auditory Verbal Learning Test delayed memory test (f=4.2, p=0.04), while the awake group improved on the Rivermead Behavioural Memory Test delayed memory test. (f=4.4, p=0.04). The Stroop III score was worse for the awake group (f=5.5, p=0.02). Worse scores were present for Stroop I (Stroop word card) (f=6.3, p=0.01), Stroop II (Stroop color card) (f=46.4, p<0.001), Stroop III (Stroop color-word card) (f=10.8, p=0.001) and Trailmaking B/A (f=4.5, p=0.04). Improvements were seen on quality of life: Parkinson's Disease Questionnaire-39 (f=24.8, p<0.001), and psychiatric scales: Hamilton Depression Rating Scale (f=6.2, p=0.01), and Hamilton Anxiety Rating Scale (f=5.5, p=0.02). CONCLUSIONS This study suggests that the choice between awake and asleep STN DBS does not affect cognitive, mood and behavioural adverse effects, despite a minor difference in memory. STN DBS has a beneficial effect on quality of life, mood and anxiety symptoms. TRIAL REGISTRATION NUMBER NTR5809.
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Affiliation(s)
- Rozemarije A Holewijn
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Thomas J C Zoon
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Isidoor O Bergfeld
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Esmée Verwijk
- Amsterdam Neuroscience, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Gert J Geurtsen
- Department of Medical Psychology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Geeske van Rooijen
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Damiaan A J P Denys
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Rob M A De Bie
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - P Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Mathiopoulou V, Rijks N, Caan MWA, Liebrand LC, Ferreira F, de Bie RMA, van den Munckhof P, Schuurman PR, Bot M. Utilizing 7-Tesla Subthalamic Nucleus Connectivity in Deep Brain Stimulation for Parkinson Disease. Neuromodulation 2023; 26:333-339. [PMID: 35216874 DOI: 10.1016/j.neurom.2022.01.003] [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: 09/23/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a highly effective surgical treatment for patients with advanced Parkinson disease (PD). Combining 7.0-Tesla (7T) T2- and diffusion-weighted imaging (DWI) sequences allows for selective segmenting of the motor part of the STN and, thus, for possible optimization of DBS. MATERIALS AND METHODS 7T T2 and DWI sequences were obtained, and probabilistic segmentation of motor, associative, and limbic STN segments was performed. Left- and right-sided motor outcome (Movement Disorders Society Unified Parkinson's Disease Rating Scale) scores were used for evaluating the correspondence between the active electrode contacts in selectively segmented STN and the clinical DBS effect. The Bejjani line was reviewed for crossing of segments. RESULTS A total of 50 STNs were segmented in 25 patients and proved highly feasible. Although the highest density of motor connections was situated in the dorsolateral STN for all patients, the exact partitioning of segments differed considerably. For all the active electrode contacts situated within the predominantly motor-connected segment of the STN, the average hemi-body Unified Parkinson's Disease Rating Scale motor improvement was 80%; outside this segment, it was 52% (p < 0.01). The Bejjani line was situated in the motor segment for 32 STNs. CONCLUSION The implementation of 7T T2 and DWI segmentation of the STN in DBS for PD is feasible and offers insight into the location of the motor segment. Segmentation-guided electrode placement is likely to further improve motor response in DBS for PD. However, commercially available DBS software for postprocessing imaging would greatly facilitate widespread implementation.
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Affiliation(s)
| | - Niels Rijks
- Department of Neurosurgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Matthan W A Caan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Luka C Liebrand
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Francisca Ferreira
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, University College London Institute of Neurology, London, UK
| | - Rob M A de Bie
- Department of Neurology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | | | - Maarten Bot
- Department of Neurosurgery, Amsterdam UMC, Amsterdam, The Netherlands.
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Rijks N, Potters WV, Dilai J, De Bie RMA, de Win M, van der Zwaag W, Schuurman R, van den Munckhof P, Bot M. Combining 7T T2 and 3T FGATIR: from physiological to anatomical identification of the subthalamic nucleus borders. J Neurol Neurosurg Psychiatry 2022; 93:1019-1020. [PMID: 35184040 DOI: 10.1136/jnnp-2021-326710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Niels Rijks
- Department of Neurosurgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Wouter V Potters
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - José Dilai
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Rob M A De Bie
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Maartje de Win
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Wietske van der Zwaag
- Royal Netherlands Academy of Arts and Sciences, Spinoza Centre for Neuroimaging, Amsterdam, The Netherlands
| | - Richard Schuurman
- Department of Neurosurgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | | | - Maarten Bot
- Department of Neurosurgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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Holewijn RA, Verbaan D, van den Munckhof PM, Bot M, Geurtsen GJ, Dijk JM, Odekerken VJ, Beudel M, de Bie RMA, Schuurman PR. General Anesthesia vs Local Anesthesia in Microelectrode Recording-Guided Deep-Brain Stimulation for Parkinson Disease: The GALAXY Randomized Clinical Trial. JAMA Neurol 2021; 78:1212-1219. [PMID: 34491267 DOI: 10.1001/jamaneurol.2021.2979] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance It is unknown if there is a difference in outcome in asleep vs awake deep brain stimulation (DBS) of the subthalamic nucleus for advanced Parkinson disease. Objective To determine the difference in adverse effects concerning cognition, mood, and behavior between awake and asleep DBS favoring the asleep arm of the study. Design, Setting, and Participants This study was a single-center prospective randomized open-label blinded end point clinical trial. A total of 187 persons with Parkinson disease were referred for DBS between May 2015 to March 2019. Analysis took place from January 2016 to January 2020. The primary outcome follow-up visit was conducted 6 months after DBS. Interventions Bilateral subthalamic nucleus DBS was performed while the patient was asleep (under general anesthesia) in 1 study arm and awake in the other study arm. Both arms of the study used a frame-based intraoperative microelectrode recording technique to refine final target placement of the DBS lead. Main Outcomes and Measures The primary outcome variable was the between-group difference in cognitive, mood, and behavioral adverse effects as measured by a composite score. The secondary outcomes included the Movement Disorders Society Unified Parkinson's Disease Rating Scale, the patient assessment of surgical burden and operative time. Results A total of 110 patients were randomized to awake (local anesthesia; n = 56; mean [SD] age, 60.0 (7.4) years; 40 [71%] male) or to asleep (general anesthesia; n = 54; mean [SD] age, 61.3 [7.9] years; 38 [70%] male) DBS surgery. The 6-month follow-up visit was completed by 103 participants. The proportion of patients with adverse cognitive, mood, and behavioral effects on the composite score was 15 of 52 (29%) after awake and 11 of 51 (22%) after asleep DBS (odds ratio, 0.7 [95% CI, 0.3-1.7]). There was no difference in improvement in the off-medication Movement Disorders Society Unified Parkinson's Disease Rating Scale Motor Examination scores between groups (awake group: mean [SD], -27.3 [17.5] points; asleep group: mean [SD], -25.3 [14.3] points; mean difference, -2.0 [95% CI, -8.1 to 4.2]). Asleep surgery was experienced as less burdensome by patients and was 26 minutes shorter than awake surgery. Conclusions and Relevance There was no difference in the primary outcome of asleep vs awake DBS. Future large randomized clinical trials should examine some of the newer asleep based DBS technologies because this study was limited to frame-based microelectrode-guided procedures. Trial Registration trialregister.nl Identifier: NTR5809.
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Affiliation(s)
- Rozemarije A Holewijn
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Pepijn M van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Gert J Geurtsen
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Joke M Dijk
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Vincent J Odekerken
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Martijn Beudel
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Rob M A de Bie
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - P Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
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Verhagen Metman L, Slavin KV, Rosenow JM, Vitek JL, van den Munckhof P. More Than Just the Level of Consciousness: Comparing Asleep and Awake Deep Brain Stimulation. Mov Disord 2021; 36:2763-2766. [PMID: 34585783 DOI: 10.1002/mds.28806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/27/2021] [Accepted: 09/11/2021] [Indexed: 02/01/2023] Open
Affiliation(s)
- Leo Verhagen Metman
- Department of Neurological Sciences, Rush University, Chicago, Illinois, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Joshua M Rosenow
- Departments of Neurosurgery, Neurology, and Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Jerrold L Vitek
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, North Holland, USA
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Merola A, Singh J, Reeves K, Changizi B, Goetz S, Rossi L, Pallavaram S, Carcieri S, Harel N, Shaikhouni A, Sammartino F, Krishna V, Verhagen L, Dalm B. New Frontiers for Deep Brain Stimulation: Directionality, Sensing Technologies, Remote Programming, Robotic Stereotactic Assistance, Asleep Procedures, and Connectomics. Front Neurol 2021; 12:694747. [PMID: 34367055 PMCID: PMC8340024 DOI: 10.3389/fneur.2021.694747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/14/2021] [Indexed: 11/21/2022] Open
Abstract
Over the last few years, while expanding its clinical indications from movement disorders to epilepsy and psychiatry, the field of deep brain stimulation (DBS) has seen significant innovations. Hardware developments have introduced directional leads to stimulate specific brain targets and sensing electrodes to determine optimal settings via feedback from local field potentials. In addition, variable-frequency stimulation and asynchronous high-frequency pulse trains have introduced new programming paradigms to efficiently desynchronize pathological neural circuitry and regulate dysfunctional brain networks not responsive to conventional settings. Overall, these innovations have provided clinicians with more anatomically accurate programming and closed-looped feedback to identify optimal strategies for neuromodulation. Simultaneously, software developments have simplified programming algorithms, introduced platforms for DBS remote management via telemedicine, and tools for estimating the volume of tissue activated within and outside the DBS targets. Finally, the surgical accuracy has improved thanks to intraoperative magnetic resonance or computerized tomography guidance, network-based imaging for DBS planning and targeting, and robotic-assisted surgery for ultra-accurate, millimetric lead placement. These technological and imaging advances have collectively optimized DBS outcomes and allowed “asleep” DBS procedures. Still, the short- and long-term outcomes of different implantable devices, surgical techniques, and asleep vs. awake procedures remain to be clarified. This expert review summarizes and critically discusses these recent innovations and their potential impact on the DBS field.
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Affiliation(s)
- Aristide Merola
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jaysingh Singh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Kevin Reeves
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Barbara Changizi
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Steven Goetz
- Medtronic PLC Neuromodulation, Minneapolis, MN, United States
| | | | | | | | - Noam Harel
- Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Ammar Shaikhouni
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Francesco Sammartino
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Vibhor Krishna
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Leo Verhagen
- Movement Disorder Section, Department of Neurological Sciences, Rush University, Chicago, IL, United States
| | - Brian Dalm
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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van den Munckhof P, Bot M, Schuurman PR. Targeting of the Subthalamic Nucleus in Patients with Parkinson's Disease Undergoing Deep Brain Stimulation Surgery. Neurol Ther 2021; 10:61-73. [PMID: 33565018 PMCID: PMC8140007 DOI: 10.1007/s40120-021-00233-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/20/2021] [Indexed: 11/29/2022] Open
Abstract
Precise stereotactic targeting of the dorsolateral motor part of the subthalamic nucleus (STN) is paramount for maximizing clinical effectiveness and preventing side effects of deep brain stimulation (DBS) in patients with advanced Parkinson's disease. With recent developments in magnetic resonance imaging (MRI) techniques, direct targeting of the dorsolateral part of the STN is now feasible, together with visualization of the motor fibers in the nearby internal capsule. However, clinically relevant discrepancies were reported when comparing STN borders on MRI to electrophysiological STN borders during microelectrode recordings (MER). Also, one should take into account the possibility of a 3D inaccuracy of up to 2 mm of the applied stereotactic technique. Pneumocephalus and image fusion errors may further increase implantation inaccuracy. Even when implantation has been successful, suboptimal lead anchoring on the skull may cause lead migration during follow-up. Meticulous pre- and intraoperative imaging is therefore indispensable, and so is postoperative imaging when the effects of DBS deteriorate during follow-up. Thus far, most DBS centers employ MRI targeting, multichannel MER, and awake test stimulation in STN surgery, but randomized trials comparing surgery under local versus general anesthesia and additional studies comparing MER-STN borders to high-field MRI-STN may change this clinical practice. Further developments in imaging protocols and improvements in image fusion processes are needed to optimize placement of DBS leads in the dorsolateral motor part of the STN in Parkinson's disease.
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Affiliation(s)
- Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands.
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Richard Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
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Park HR, Lim YH, Song EJ, Lee JM, Park K, Park KH, Lee WW, Kim HJ, Jeon B, Paek SH. Bilateral Subthalamic Nucleus Deep Brain Stimulation under General Anesthesia: Literature Review and Single Center Experience. J Clin Med 2020; 9:jcm9093044. [PMID: 32967337 PMCID: PMC7564882 DOI: 10.3390/jcm9093044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
Bilateral subthalamic nucleus (STN) Deep brain stimulation (DBS) is a well-established treatment in patients with Parkinson's disease (PD). Traditionally, STN DBS for PD is performed by using microelectrode recording (MER) and/or intraoperative macrostimulation under local anesthesia (LA). However, many patients cannot tolerate the long operation time under LA without medication. In addition, it cannot be even be performed on PD patients with poor physical and neurological condition. Recently, it has been reported that STN DBS under general anesthesia (GA) can be successfully performed due to the feasible MER under GA, as well as the technical advancement in direct targeting and intraoperative imaging. The authors reviewed the previously published literature on STN DBS under GA using intraoperative imaging and MER, focused on discussing the technique, clinical outcome, and the complication, as well as introducing our single-center experience. Based on the reports of previously published studies and ours, GA did not interfere with the MER signal from STN. STN DBS under GA without intraoperative stimulation shows similar or better clinical outcome without any additional complication compared to STN DBS under LA. Long-term follow-up with a large number of the patients would be necessary to validate the safety and efficacy of STN DBS under GA.
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Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea;
| | - Yong Hoon Lim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
| | - Eun Jin Song
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
| | - Jae Meen Lee
- Department of Neurosurgery, Pusan National University Hospital, Busan 49241, Korea;
| | - Kawngwoo Park
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Korea;
| | - Kwang Hyon Park
- Department of Neurosurgery, Chuungnam National University Sejong Hospital, Sejong 30099, Korea;
| | - Woong-Woo Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Korea;
| | - Han-Joon Kim
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (H.-J.K.); (B.J.)
| | - Beomseok Jeon
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (H.-J.K.); (B.J.)
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
- Correspondence: ; Tel.: +82-22-072-2876
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Holewijn RA, Bot M, van den Munckhof P, Schuurman PR. Implementation of Intraoperative Cone-Beam Computed Tomography (O-arm) for Stereotactic Imaging During Deep Brain Stimulation Procedures. Oper Neurosurg (Hagerstown) 2020; 19:E224-E229. [PMID: 32392290 PMCID: PMC7530565 DOI: 10.1093/ons/opaa110] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 03/05/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Intraoperative cone-beam computed tomography (iCBCT) allows for rapid 3-dimensional imaging. However, it is currently unknown whether this imaging technique offers sufficient accuracy for stereotactic registration during deep brain stimulation (DBS) procedures. OBJECTIVE To determine the accuracy of iCBCT, with the O-arm O2 (Medtronic), for stereotactic registration by comparing this modality to stereotactic magnetic resonance imaging (MRI). METHODS All DBS patients underwent a preoperative non-stereotactic 3 Tesla MRI, stereotactic 1.5 Tesla MRI, stereotactic O-arm iCBCT, postimplantation O-arm iCBCT, and postoperative conventional multidetector computed tomography (CT) scan. We compared stereotactic (X, Y, and Z) coordinates of the anterior commissure (AC), the posterior commissure (PC), and midline reference (MR) between stereotactic MRI and iCBCT. For localisation comparison of electrode contacts, stereotactic coordinates of electrode tips were compared between the postoperative multidetector CT and iCBCT. RESULTS A total of 20 patients were evaluated. The average absolute difference in stereotactic coordinates of AC, PC, and MR was 0.4 ± 0.4 mm for X, 0.4 ± 0.4 mm for Y, and 0.7 ± 0.5 mm for Z. The average absolute difference in X-, Y-, and Z-coordinates for electrode localisation (N = 34) was 0.3 ± 0.3 mm, 0.6 ± 0.3 mm, and 0.6 ± 0.6 mm. These differences were small enough not to be considered clinically relevant. CONCLUSION Stereotactic MRI and O-arm iCBCT yield comparable coordinates in pre- and postoperative imaging. Differences found are below the threshold of clinical relevance. Intraoperative O-arm CBCT offers rapid stereotactic registration and evaluation of electrode placement. This increases patient comfort and neurosurgical workflow efficiency.
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Affiliation(s)
- Rozemarije A Holewijn
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Richard Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
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Senemmar F, Hartmann CJ, Slotty PJ, Vesper J, Schnitzler A, Groiss SJ. Asleep Surgery May Improve the Therapeutic Window for Deep Brain Stimulation of the Subthalamic Nucleus. Neuromodulation 2020; 24:279-285. [PMID: 32662156 DOI: 10.1111/ner.13237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The effect of anesthesia type in terms of asleep vs. awake deep brain stimulation (DBS) surgery on therapeutic window (TW) has not been investigated so far. The objective of the study was to investigate whether asleep DBS surgery of the subthalamic nucleus (STN) improves TW for both directional (dDBS) and omnidirectional (oDBS) stimulation in a large single-center population. MATERIALS AND METHODS A total of 104 consecutive patients with Parkinson's disease (PD) undergoing STN-DBS surgery (80 asleep and 24 awake) were compared regarding TW, therapeutic threshold, side effect threshold, improvement of Unified PD Rating Scale motor score (UPDRS-III) and degree of levodopa equivalent daily dose (LEDD) reduction. RESULTS Asleep DBS surgery led to significantly wider TW compared to awake surgery for both dDBS and oDBS. However, dDBS further increased TW compared to oDBS in the asleep group only and not in the awake group. Clinical efficacy in terms of UPDRS-III improvement and LEDD reduction did not differ between groups. CONCLUSIONS Our study provides first evidence for improvement of therapeutic window by asleep surgery compared to awake surgery, which can be strengthened further by dDBS. These results support the notion of preferring asleep over awake surgery but needs to be confirmed by prospective trials.
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Affiliation(s)
- Farhad Senemmar
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian J Hartmann
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Neurosurgical Clinic, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Neurosurgical Clinic, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Frequin HL, Bot M, Dilai J, Scholten MN, Postma M, Bour LJ, Contarino MF, de Bie RMA, Schuurman PR, van den Munckhof P. Relative Contribution of Magnetic Resonance Imaging, Microelectrode Recordings, and Awake Test Stimulation in Final Lead Placement during Deep Brain Stimulation Surgery of the Subthalamic Nucleus in Parkinson's Disease. Stereotact Funct Neurosurg 2020; 98:118-128. [PMID: 32131066 DOI: 10.1159/000505710] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/31/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION For deep brain stimulation (DBS) surgery of the subthalamic nucleus (STN) in Parkinson's disease (PD), many centers employ visualization of the nucleus on magnetic resonance imaging (MRI), intraoperative microelectrode recordings (MER), and test stimulation in awake patients. The value of these steps is a subject for ongoing debate. In the current study, we determined the relative contribution of MRI targeting, multitrack MER, and awake test stimulation in final lead placement during STN DBS surgery for PD. METHODS Data on PD patients undergoing MRI-targeted STN DBS surgery with three-channel MER and awake test stimulation between February 2010 and January 2014 were analyzed to determine in which MER trajectory final leads were implanted and why this tract was chosen. RESULTS Seventy-six patients underwent implantation of 146 DBS leads. In 92% of the STN, the final leads were implanted in one of the three planned channels. In 6%, additional channels were needed. In 2%, surgery was aborted before final lead implantation due to anxiety or fatigue. The final leads were implanted in the channels with the longest STN MER signal trajectory in 60% of the STN (38% of the bilaterally implanted patients). This was the central channel containing the MRI target in 39% of the STN (18% bilaterally). The most frequently noted reasons why another channel than the central channel was chosen for final lead placement were (1) a lower threshold for side effects (54%) and (2) no or a too short trajectory of the STN MER signal (40%) in the central channel. The latter reason correlated with larger 2D (x and y) errors in our stereotactic method. CONCLUSIONS STN DBS leads were often not implanted in the MRI-planned trajectory or in the trajectory with the longest STN MER signal. Thresholds for side effects during awake test stimulation were decisive for final target selection in the majority of patients.
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Affiliation(s)
- Henrieke L Frequin
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - José Dilai
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Marije N Scholten
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Miranda Postma
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Lodewijk J Bour
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Rob M A de Bie
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands,
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Burchiel KJ, Kinsman M, Mansfield K, Mitchell A. Verification of the Deep Brain Stimulation Electrode Position Using Intraoperative Electromagnetic Localization. Stereotact Funct Neurosurg 2020; 98:37-42. [PMID: 32018272 DOI: 10.1159/000505494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electromagnetic (EM) localization has typically been used to direct shunt catheters into the ventricle. The objective of this study was to determine if this method of EM tracking could be used in a deep brain stimulation (DBS) electrode cannula to accurately predict the eventual location of the electrode contacts. METHODS The Medtronic AxiEMTM system was used to generate the cannula tip location directed to the planned target site. Prior to clinical testing, a series of phantom modelling observations were made. RESULTS Phantom trials (n = 23) demonstrated that the cannula tip could be accurately located at the target site with an error of between 0.331 ± 0.144 and 0.6 ± 0.245 mm, depending on the orientation of the delivery system to the axis of the phantom head. Intraoperative EM localization of the DBS cannula was performed in 84 trajectories in 48 patients. The average difference between the planned target and the EM stylet location at the cannula tip was 1.036 ± 0.543 mm. The average error between the planned target coordinates and the actual target electrode location (by CT) was 1.431 ± 0.607 and 1.145 ± 0.636 mm for the EM stylet location in the cannula (p = 0.00312), indicating that EM localization reflected the position of the target electrode more accurately than the planned target. CONCLUSIONS EM localization can be used to verify the position of DBS electrodes intraoperatively with a high accuracy.
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Affiliation(s)
- Kim J Burchiel
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA,
| | - Michael Kinsman
- Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kevin Mansfield
- Department of Neurosurgery, Mercy Clinic, Springfield, Missouri, USA
| | - Ann Mitchell
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Boavista Barros Heil L, Leme Silva P, Ferreira Cruz F, Pelosi P, Rieken Macedo Rocco P. Immunomodulatory effects of anesthetic agents in perioperative medicine. Minerva Anestesiol 2020; 86:181-195. [DOI: 10.23736/s0375-9393.19.13627-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wang J, Ponce FA, Tao J, Yu HM, Liu JY, Wang YJ, Luan GM, Ou SW. Comparison of Awake and Asleep Deep Brain Stimulation for Parkinson's Disease: A Detailed Analysis Through Literature Review. Neuromodulation 2019; 23:444-450. [PMID: 31830772 DOI: 10.1111/ner.13061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/22/2019] [Accepted: 09/11/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) for Parkinson's disease (PD) has been applied to clinic for approximately 30 years. The goal of this review is to explore the similarities and differences between "awake" and "asleep" DBS techniques. METHODS A comprehensive literature review was carried out to identify relevant studies and review articles describing applications of "awake" or "asleep" DBS for Parkinson's disease. The surgical procedures, clinical outcomes, costs and complications of each technique were compared in detail through literature review. RESULTS The surgical procedures of awake and asleep DBS surgeries rely upon different methods for verification of intended target acquisition. The existing research results demonstrated that the stereotactic targeting accuracy of lead placement obtained by either method is reliable. There were no significant differences in clinical outcomes, costs, or complications between the two techniques. CONCLUSION The surgical and clinical outcomes of asleep DBS for PD are comparable to those of awake DBS.
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Affiliation(s)
- Jun Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jun Tao
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Hong-Mei Yu
- Department of Neurology, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Ji-Yuan Liu
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Yun-Jie Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Guo-Ming Luan
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, P. R., China
| | - Shao-Wu Ou
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
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