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Mayer R, Desai K, Aguiar RSDT, McClure JJ, Kato N, Kalman C, Pilitsis JG. Evolution of Deep Brain Stimulation Techniques for Complication Mitigation. Oper Neurosurg (Hagerstown) 2024; 27:148-157. [PMID: 38315020 DOI: 10.1227/ons.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/07/2023] [Indexed: 02/07/2024] Open
Abstract
Complication mitigation in deep brain stimulation has been a topic matter of much discussion in the literature. In this article, we examine how neurosurgeons as individuals and as a field generated and adapted techniques to prevent infection, lead fracture/lead migration, and suboptimal outcomes in both the acute period and longitudinally. The authors performed a MEDLINE search inclusive of articles from 1987 to June 2023 including human studies written in English. Using the Rayyan platform, two reviewers (J.P. and R.M.) performed a title screen. Of the 776 articles, 252 were selected by title screen and 172 from abstract review for full-text evaluation. Ultimately, 124 publications were evaluated. We describe the initial complications and inefficiencies at the advent of deep brain stimulation and detail changes instituted by surgeons that reduced them. Furthermore, we discuss the trend in both undesired short-term and long-term outcomes with emphasis on how surgeons recognized and modified their practice to provide safer and better procedures. This scoping review adds to the literature as a guide to both new neurosurgeons and seasoned neurosurgeons alike to understand better what innovations have been trialed over time as we embark on novel targets and neuromodulatory technologies.
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Affiliation(s)
- Ryan Mayer
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton , Florida , USA
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Zagorchev L, Hyde DE, Li C, Wenzel F, Fläschner N, Ewald A, O'Donoghue S, Hancock K, Lim RX, Choi DC, Kelly E, Gupta S, Wilden J. Shape-constrained deformable brain segmentation: Methods and quantitative validation. Neuroimage 2024; 289:120542. [PMID: 38369167 DOI: 10.1016/j.neuroimage.2024.120542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024] Open
Abstract
MRI-guided neuro interventions require rapid, accurate, and reproducible segmentation of anatomical brain structures for identification of targets during surgical procedures and post-surgical evaluation of intervention efficiency. Segmentation algorithms must be validated and cleared for clinical use. This work introduces a methodology for shape-constrained deformable brain segmentation, describes the quantitative validation used for its clinical clearance, and presents a comparison with manual expert segmentation and FreeSurfer, an open source software for neuroimaging data analysis. ClearPoint Maestro is software for fully-automatic brain segmentation from T1-weighted MRI that combines a shape-constrained deformable brain model with voxel-wise tissue segmentation within the cerebral hemispheres and the cerebellum. The performance of the segmentation was validated in terms of accuracy and reproducibility. Segmentation accuracy was evaluated with respect to training data and independently traced ground truth. Segmentation reproducibility was quantified and compared with manual expert segmentation and FreeSurfer. Quantitative reproducibility analysis indicates superior performance compared to both manual expert segmentation and FreeSurfer. The shape-constrained methodology results in accurate and highly reproducible segmentation. Inherent point based-correspondence provides consistent target identification ideal for MRI-guided neuro interventions.
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Affiliation(s)
- Lyubomir Zagorchev
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA.
| | - Damon E Hyde
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Chen Li
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Fabian Wenzel
- Philips Research Hamburg, Medical Image Processing and Analytics, Röntgenstraße 24-26, Hamburg, 22335, Germany
| | - Nick Fläschner
- Philips Research Hamburg, Medical Image Processing and Analytics, Röntgenstraße 24-26, Hamburg, 22335, Germany
| | - Arne Ewald
- Philips Research Hamburg, Medical Image Processing and Analytics, Röntgenstraße 24-26, Hamburg, 22335, Germany
| | - Stefani O'Donoghue
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Kelli Hancock
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Ruo Xuan Lim
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Dennis C Choi
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Eddie Kelly
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Shruti Gupta
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
| | - Jessica Wilden
- ClearPoint Neuro, Clinical Science and Applications, 120 S. Sierra Ave., Suite 100, Solana Beach, 92075, CA, USA
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Qiu L, Xu E, Chambule S, LaTourette P, Dyer CD, Wallace CK, Donocoff R, Wilson JM, Lucas TH, Chen HI. Magnetic Resonance Imaging-Guided Frameless Stereotactic Injections of the Bilateral Cerebellar Dentate Nuclei in Nonhuman Primates: Technical Note. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01040. [PMID: 38310346 DOI: 10.1227/ons.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/20/2023] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Nonhuman primates (NHPs) are important preclinical models for evaluating therapeutics because of their anatomophysiological similarities to humans, and can be especially useful for testing new delivery targets. With the growing promise of cell and gene therapies for the treatment of neurological diseases, it is important to ensure the accurate and safe delivery of these agents to target structures in the brain. However, a standard guideline or method has not been developed for stereotactic targeting in NHPs. In this article, we describe the safe use of a magnetic resonance imaging-guided frameless stereotactic system to target bilateral cerebellar dentate nuclei for accurate, real-time delivery of viral vector in NHPs. METHODS Seventeen rhesus macaques (Macaca mulatta) underwent stereotactic surgery under real-time MRI guidance using the ClearPoint® system. Bilateral cerebellar dentate nuclei were targeted through a single parietal entry point with a transtentorial approach. Fifty microliters of contrast-impregnated infusate was delivered to each dentate nucleus, and adjustments were made as necessary according to real-time MRI monitoring of delivery. Perioperative clinical outcomes and postoperative volumes of distribution were recorded. RESULTS All macaques underwent bilateral surgery successfully. Superficial pin site infection occurred in 4/17 (23.5%) subjects, which resolved with antibiotics. Two episodes of transient neurological deficit (anisocoria and unilateral weakness) were recorded, which did not require additional postoperative treatment and resolved over time. Volume of distribution of infusate achieved satisfactory coverage of target dentate nuclei, and only 1 incidence (2.9%) of cerebrospinal fluid penetration was recorded. Mean volume of distribution was 161.22 ± 39.61 mm3 (left, 173.65 ± 48.29; right, 148.80 ± 23.98). CONCLUSION MRI-guided frameless stereotactic injection of bilateral cerebellar dentate nuclei in NHPs is safe and feasible. The use of this technique enables real-time modification of the surgical plan to achieve adequate target coverage and can be readily translated to clinical use.
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Affiliation(s)
- Liming Qiu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Xu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sydney Chambule
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip LaTourette
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Current Affiliation: Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Cecilia D Dyer
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chelsea K Wallace
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Donocoff
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Current Affiliation: Bristol Myers Squibb, Princeton, New Jersey, USA
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy H Lucas
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - H Isaac Chen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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He Z, Dai J, Ho JDL, Tong HS, Wang X, Fang G, Liang L, Cheung CL, Guo Z, Chang HC, Iordachita I, Taylor RH, Poon WS, Chan DTM, Kwok KW. Interactive Multi-Stage Robotic Positioner for Intra-Operative MRI-Guided Stereotactic Neurosurgery. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2305495. [PMID: 38072667 PMCID: PMC10870025 DOI: 10.1002/advs.202305495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/30/2023] [Indexed: 02/17/2024]
Abstract
Magnetic resonance imaging (MRI) demonstrates clear advantages over other imaging modalities in neurosurgery with its ability to delineate critical neurovascular structures and cancerous tissue in high-resolution 3D anatomical roadmaps. However, its application has been limited to interventions performed based on static pre/post-operative imaging, where errors accrue from stereotactic frame setup, image registration, and brain shift. To leverage the powerful intra-operative functions of MRI, e.g., instrument tracking, monitoring of physiological changes and tissue temperature in MRI-guided bilateral stereotactic neurosurgery, a multi-stage robotic positioner is proposed. The system positions cannula/needle instruments using a lightweight (203 g) and compact (Ø97 × 81 mm) skull-mounted structure that fits within most standard imaging head coils. With optimized design in soft robotics, the system operates in two stages: i) manual coarse adjustment performed interactively by the surgeon (workspace of ±30°), ii) automatic fine adjustment with precise (<0.2° orientation error), responsive (1.4 Hz bandwidth), and high-resolution (0.058°) soft robotic positioning. Orientation locking provides sufficient transmission stiffness (4.07 N/mm) for instrument advancement. The system's clinical workflow and accuracy is validated with lab-based (<0.8 mm) and MRI-based testing on skull phantoms (<1.7 mm) and a cadaver subject (<2.2 mm). Custom-made wireless omni-directional tracking markers facilitated robot registration under MRI.
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Affiliation(s)
- Zhuoliang He
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
| | - Jing Dai
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
| | - Justin Di-Lang Ho
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
| | - Hon-Sing Tong
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
| | - Xiaomei Wang
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
- Multi-Scale Medical Robotics Center, Hong Kong, 999077, China
| | - Ge Fang
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
| | - Liyuan Liang
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Hong Kong, 999077, China
- Multi-Scale Medical Robotics Center, Hong Kong, 999077, China
| | - Chim-Lee Cheung
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
| | - Ziyan Guo
- Department of Medical Physics and Biomedical Engineering, University College London, London, WC1E 6BT, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, WC1E 6BT, UK
| | - Hing-Chiu Chang
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Hong Kong, 999077, China
- Multi-Scale Medical Robotics Center, Hong Kong, 999077, China
| | - Iulian Iordachita
- Department of Mechanical Engineering and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Russell H Taylor
- Department of Computer Science and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Wai-Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, 999077, China
- Neuromedicine Center, Shenzhen Hospital, The University of Hong Kong, Shenzhen, 518053, China
| | - Danny Tat-Ming Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, 999077, China
- Multi-Scale Medical Robotics Center, Hong Kong, 999077, China
| | - Ka-Wai Kwok
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, 999077, China
- Multi-Scale Medical Robotics Center, Hong Kong, 999077, China
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Rissardo JP, Vora NM, Tariq I, Mujtaba A, Caprara ALF. Deep Brain Stimulation for the Management of Refractory Neurological Disorders: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1991. [PMID: 38004040 PMCID: PMC10673515 DOI: 10.3390/medicina59111991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
In recent decades, deep brain stimulation (DBS) has been extensively studied due to its reversibility and significantly fewer side effects. DBS is mainly a symptomatic therapy, but the stimulation of subcortical areas by DBS is believed to affect the cytoarchitecture of the brain, leading to adaptability and neurogenesis. The neurological disorders most commonly studied with DBS were Parkinson's disease, essential tremor, obsessive-compulsive disorder, and major depressive disorder. The most precise approach to evaluating the location of the leads still relies on the stimulus-induced side effects reported by the patients. Moreover, the adequate voltage and DBS current field could correlate with the patient's symptoms. Implantable pulse generators are the main parts of the DBS, and their main characteristics, such as rechargeable capability, magnetic resonance imaging (MRI) safety, and device size, should always be discussed with patients. The safety of MRI will depend on several parameters: the part of the body where the device is implanted, the part of the body scanned, and the MRI-tesla magnetic field. It is worth mentioning that drug-resistant individuals may have different pathophysiological explanations for their resistance to medications, which could affect the efficacy of DBS therapy. Therefore, this could explain the significant difference in the outcomes of studies with DBS in individuals with drug-resistant neurological conditions.
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Affiliation(s)
| | - Nilofar Murtaza Vora
- Medicine Department, Terna Speciality Hospital and Research Centre, Navi Mumbai 400706, India;
| | - Irra Tariq
- Medicine Department, United Medical & Dental College, Karachi 75600, Pakistan;
| | - Amna Mujtaba
- Medicine Department, Karachi Medical & Dental College, Karachi 74700, Pakistan;
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Chuang TC, Tan JQ, Chen SM. Comparison of intraoperative imaging guided versus microelectrode recording guided deep brain stimulation for Parkinson's disease: A meta-analysis. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:228-237. [PMID: 36931932 DOI: 10.1016/j.neucie.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 09/12/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND Traditionally, most centers would use microelectrode recording (MER) to refine targeting in deep brain stimulation (DBS) surgery. In recent years, intraoperative imaging (IMG) guided DBS has become an alternative way to verify lead placement. Currently, there is still controversy surrounding the necessity of MER or IMG for DBS. This meta-analysis aims to explore lead accuracy, clinical efficacy and safety between IMG and MER guided DBS for Parkinson's disease (PD). METHODS PubMed, Embase, Web of Science, Cochrane Library were searched up to Mar, 2021 for studies reporting comparisons between IMG and MER guided DBS for PD. Subgroup analysis was conducted to assess effects of different IMG technology and DBS targeting site. RESULTS Six studies, comprising of 478 patients were included in our analysis. The mean difference between the two implantation techniques in stereotactic accuracy, lead passes per trajectory, improvement% of Unified Parkinson's Disease Rating Scale part III and levodopa equivalent daily dose were -0.45 (95% confidence interval, CI=-1.11 to 0.20), -0.18 (95% CI=-0.41 to 0.06), 3.40 (95% CI=-5.36 to 12.16), and 5.00 (95% CI=-1.40 to 11.39), respectively. No significant differences were observed in each adverse event and operation/procedure time between the two implantation techniques. CONCLUSIONS Both IMG and MER guided DBS offered effective control of motor symptoms for PD. Besides, IMG guided is comparable to MER guided DBS, in terms of safety, accuracy and efficiency. It is recommended for each hospital to select DBS guidance technology based on available resources and equipment.
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Affiliation(s)
- Tsung-Che Chuang
- Department of Primary Medicine, Shuang-Ho Hospital, New Taipei, Taiwan
| | - Jia-Qi Tan
- Department of Primary Medicine, Shuang-Ho Hospital, New Taipei, Taiwan
| | - Shu-Mei Chen
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.
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Kons Z, Hadanny A, Bush A, Nanda P, Herrington TM, Richardson RM. Accurate Deep Brain Stimulation Lead Placement Concurrent With Research Electrocorticography. Oper Neurosurg (Hagerstown) 2023; 24:524-532. [PMID: 36701668 PMCID: PMC10158863 DOI: 10.1227/ons.0000000000000582] [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: 06/29/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Using electrocorticography for research (R-ECoG) during deep brain stimulation (DBS) surgery has advanced our understanding of human cortical-basal ganglia neurophysiology and mechanisms of therapeutic circuit modulation. The safety of R-ECoG has been established, but potential effects of temporary ECoG strip placement on targeting accuracy have not been reported. OBJECTIVE To determine whether temporary subdural electrode strip placement during DBS implantation surgery affects lead implantation accuracy. METHODS Twenty-four consecutive patients enrolled in a prospective database who underwent awake DBS surgery were identified. Ten of 24 subjects participated in R-ECoG. Lead locations were determined after fusing postoperative computed tomography scans into the surgical planning software. The effect of brain shift was quantified using Lead-DBS and analyzed in a mixed-effects model controlling for time interval to postoperative computed tomography. Targeting accuracy was reported as radial and Euclidean distance errors and compared with Mann-Whitney tests. RESULTS Neither radial error nor Euclidean distance error differed significantly between R-ECoG participants and nonparticipants. Pneumocephalus volume did not differ between the 2 groups, but brain shift was slightly greater with R-ECoG. Pneumocephalus volume correlated with brain shift, but neither of these measures significantly correlated with Euclidean distance error. There were no complications in either group. CONCLUSION In addition to an excellent general safety profile as has been reported previously, these results suggest that performing R-ECoG during DBS implantation surgery does not affect the accuracy of lead placement.
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Affiliation(s)
- Zachary Kons
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA;
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA;
| | - Amir Hadanny
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA;
| | - Alan Bush
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA;
- Harvard Medical School, Boston, Massachusetts, USA;
| | - Pranav Nanda
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA;
| | - Todd M. Herrington
- Harvard Medical School, Boston, Massachusetts, USA;
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA;
| | - R. Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA;
- Harvard Medical School, Boston, Massachusetts, USA;
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Kremer NI, van Laar T, Lange SF, Statius Muller S, la Bastide-van Gemert S, Oterdoom DM, Drost G, van Dijk JMC. STN-DBS electrode placement accuracy and motor improvement in Parkinson's disease: systematic review and individual patient meta-analysis. J Neurol Neurosurg Psychiatry 2023; 94:236-244. [PMID: 36207065 DOI: 10.1136/jnnp-2022-329192] [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: 03/05/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective neurosurgical treatment for Parkinson's disease. Surgical accuracy is a critical determinant to achieve an adequate DBS effect on motor performance. A two-millimetre surgical accuracy is commonly accepted, but scientific evidence is lacking. A systematic review and meta-analysis of study-level and individual patient data (IPD) was performed by a comprehensive search in MEDLINE, EMBASE and Cochrane Library. Primary outcome measures were (1) radial error between the implanted electrode and target; (2) DBS motor improvement on the Unified Parkinson's Disease Rating Scale part III (motor examination). On a study level, meta-regression analysis was performed. Also, publication bias was assessed. For IPD meta-analysis, a linear mixed effects model was used. Forty studies (1391 patients) were included, reporting radial errors of 0.45-1.86 mm. Errors within this range did not significantly influence the DBS effect on motor improvement. Additional IPD analysis (206 patients) revealed that a mean radial error of 1.13±0.75 mm did not significantly change the extent of DBS motor improvement. Our meta-analysis showed a huge publication bias on accuracy data in DBS. Therefore, the current literature does not provide an unequivocal upper threshold for acceptable accuracy of STN-DBS surgery. Based on the current literature, DBS-electrodes placed within a 2 mm range of the intended target do not have to be repositioned to enhance motor improvement after STN-DBS for Parkinson's disease. However, an indisputable upper cut-off value for surgical accuracy remains to be established. PROSPERO registration number is CRD42018089539.
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Affiliation(s)
- Naomi I Kremer
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Teus van Laar
- Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stèfan F Lange
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sijmen Statius Muller
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Dl Marinus Oterdoom
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gea Drost
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Pivazyan G, Sandhu FA, Beaufort AR, Cunningham BW. Basis for error in stereotactic and computer-assisted surgery in neurosurgical applications: literature review. Neurosurg Rev 2022; 46:20. [PMID: 36536143 DOI: 10.1007/s10143-022-01928-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 11/29/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Technological advancements in optoelectronic motion capture systems have allowed for the development of high-precision computer-assisted surgery (CAS) used in cranial and spinal surgical procedures. Errors generated sequentially throughout the chain of components of CAS may have cumulative effect on the accuracy of implant and instrumentation placement - potentially affecting patient outcomes. Navigational integrity and maintenance of fidelity of optoelectronic data is the cornerstone of CAS. Error reporting measures vary between studies. Understanding error generation, mechanisms of propagation, and how they relate to workflow can assist clinicians in error mitigation and improve accuracy during navigation in neurosurgical procedures. Diligence in planning, fiducial positioning, system registration, and intra-operative workflow have the potential to improve accuracy and decrease disparity between planned and final instrumentation and implant position. This study reviews the potential errors associated with each step in computer-assisted surgery and provides a basis for disparity in intrinsic accuracy versus achieved accuracy in the clinical operative environment.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.
- Musculoskeletal Education Center, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA.
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | | | - Bryan W Cunningham
- Musculoskeletal Education Center, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Comparison of intraoperative imaging guided versus microelectrode recording guided deep brain stimulation for Parkinson's disease: A meta-analysis. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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11
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Lee AT, Han KJ, Nichols N, Sudhakar VR, Burke JF, Wozny TA, Chung JE, Volz MM, Ostrem JL, Martin AJ, Larson PS, Starr PA, Wang DD. Targeting Accuracy and Clinical Outcomes of Awake Vs Asleep Interventional MRI-Guided Deep Brain Stimulation for Parkinson's Disease: The UCSF Experience. Neurosurgery 2022; 91:717-725. [PMID: 36069560 DOI: 10.1227/neu.0000000000002111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Interventional MRI (iMRI)-guided implantation of deep brain stimulator (DBS) leads has been developed to treat patients with Parkinson's disease (PD) without the need for awake testing. OBJECTIVE Direct comparisons of targeting accuracy and clinical outcomes for awake stereotactic with asleep iMRI-DBS for PD are limited. METHODS We performed a retrospective review of patients with PD who underwent awake or iMRI-guided DBS surgery targeting the subthalamic nucleus or globus pallidus interna between 2013 and 2019 at our institution. Outcome measures included Unified Parkinson's Disease Rating Scale Part III scores, levodopa equivalent daily dose, radial error between intended and actual lead locations, stimulation parameters, and complications. RESULTS Of the 218 patients included in the study, the iMRI cohort had smaller radial errors (iMRI: 1.27 ± 0.72 mm, awake: 1.59 ± 0.96 mm, P < .01) and fewer lead passes (iMRI: 1.0 ± 0.16, awake: 1.2 ± 0.41, P < .01). Changes in Unified Parkinson's Disease Rating Scale were similar between modalities, but awake cases had a greater reduction in levodopa equivalent daily dose than iMRI cases (P < .01), which was attributed to the greater number of awake subthalamic nucleus cases on multivariate analysis. Effective clinical contacts used for stimulation, side effect thresholds, and complication rates were similar between modalities. CONCLUSION Although iMRI-DBS may result in more accurate lead placement for intended target compared with awake-DBS, clinical outcomes were similar between surgical approaches. Ultimately, patient preference and surgeon experience with a given DBS technique should be the main factors when determining the "best" method for DBS implantation.
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Affiliation(s)
- Anthony T Lee
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kasey J Han
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Noah Nichols
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Vivek R Sudhakar
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John F Burke
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jason E Chung
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Monica M Volz
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jill L Ostrem
- Department of Neurology, Movement Disorders and Neuromodulation Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Alastair J Martin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Paul S Larson
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Philip A Starr
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Doris D Wang
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
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12
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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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13
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Kochanski RB, Slavin KV. The future perspectives of psychiatric neurosurgery. PROGRESS IN BRAIN RESEARCH 2022; 270:211-228. [PMID: 35396029 DOI: 10.1016/bs.pbr.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The future of psychiatric neurosurgery can be viewed from two separate perspectives: the immediate future and the distant future. Both show promise, but the treatment strategy for mental diseases and the technology utilized during these separate periods will likely differ dramatically. It can be expected that the initial advancements will be built upon progress of neuroimaging and stereotactic targeting while surgical technology becomes adapted to patient-specific symptomatology and structural/functional imaging parameters. This individualized approach has already begun to show significant promise when applied to deep brain stimulation for treatment-resistant depression and obsessive-compulsive disorder. If effectiveness of these strategies is confirmed by well designed, double-blind, placebo-controlled clinical studies, further technological advances will continue into the distant future, and will likely involve precise neuromodulation at the cellular level, perhaps using wireless technology with or without closed-loop design. This approach, being theoretically less invasive and carrying less risk, may ultimately propel psychiatric neurosurgery to the forefront in the treatment algorithm of mental illness. Despite prominent development of non-invasive therapeutic options, such as stereotactic radiosurgery or transcranial magnetic resonance-guided focused ultrasound, chances are there will still be a need in surgical management of patients with most intractable psychiatric conditions.
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Affiliation(s)
- Ryan B Kochanski
- Neurosurgery, Methodist Healthcare System, San Antonio, TX, United States
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States; Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, IL, United States.
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14
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Bandopadhyay R, Mishra N, Rana R, Kaur G, Ghoneim MM, Alshehri S, Mustafa G, Ahmad J, Alhakamy NA, Mishra A. Molecular Mechanisms and Therapeutic Strategies for Levodopa-Induced Dyskinesia in Parkinson’s Disease: A Perspective Through Preclinical and Clinical Evidence. Front Pharmacol 2022; 13:805388. [PMID: 35462934 PMCID: PMC9021725 DOI: 10.3389/fphar.2022.805388] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 02/21/2022] [Indexed: 12/20/2022] Open
Abstract
Parkinson’s disease (PD) is the second leading neurodegenerative disease that is characterized by severe locomotor abnormalities. Levodopa (L-DOPA) treatment has been considered a mainstay for the management of PD; however, its prolonged treatment is often associated with abnormal involuntary movements and results in L-DOPA-induced dyskinesia (LID). Although LID is encountered after chronic administration of L-DOPA, the appearance of dyskinesia after weeks or months of the L-DOPA treatment has complicated our understanding of its pathogenesis. Pathophysiology of LID is mainly associated with alteration of direct and indirect pathways of the cortico-basal ganglia-thalamic loop, which regulates normal fine motor movements. Hypersensitivity of dopamine receptors has been involved in the development of LID; moreover, these symptoms are worsened by concurrent non-dopaminergic innervations including glutamatergic, serotonergic, and peptidergic neurotransmission. The present study is focused on discussing the recent updates in molecular mechanisms and therapeutic approaches for the effective management of LID in PD patients.
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Affiliation(s)
- Ritam Bandopadhyay
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India
| | - Nainshi Mishra
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India
| | - Ruhi Rana
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India
| | - Gagandeep Kaur
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India
| | - Mohammed M. Ghoneim
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Ad Diriyah, Saudi Arabia
| | - Sultan Alshehri
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Gulam Mustafa
- College of Pharmacy (Boys), Al-Dawadmi Campus, Shaqra University, Riyadh, Saudi Arabia
| | - Javed Ahmad
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran, Saudi Arabia
| | - Nabil. A. Alhakamy
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Awanish Mishra
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)—Guwahati, Guwahati, India
- *Correspondence: Awanish Mishra, ,
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15
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Musa MJ, Carpenter AB, Kellner C, Sigounas D, Godage I, Sengupta S, Oluigbo C, Cleary K, Chen Y. Minimally Invasive Intracerebral Hemorrhage Evacuation: A review. Ann Biomed Eng 2022; 50:365-386. [PMID: 35226279 DOI: 10.1007/s10439-022-02934-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/11/2022] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a leading cause of morbidity and mortality worldwide. To date, there is no specific treatment that clearly provides a benefit in functional outcome or mortality. Surgical treatment for hematoma evacuation has not yet shown clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment. In this paper, we review intracerebral hemorrhage pathology, currently available treatments, and potential robotic approaches to date. We also discuss the future role of robotics in stroke treatment.
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Affiliation(s)
- Mishek J Musa
- Department of Mechanical Engineering, University of Arkansas, Fayetteville, AR, USA
| | | | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, The George Washington University, Washington, Washington, DC, USA
| | - Isuru Godage
- College of Computing and Digital Media, DePaul University, Chicago, IL, USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chima Oluigbo
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Kevin Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Yue Chen
- Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA.
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16
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Patra DP, Welz ME, Turcotte EL, Pandey R, Vij K, Daly M, Rabon M, Korszen S, Zhou Y, Halpin B, Marchese ML, Syal A, Krishna C, Bendok BR. Real-Time MRI-Guided Stereotactic Aspiration of Spontaneous Intracerebral Hematoma: A Preclinical Feasibility Study. Oper Neurosurg (Hagerstown) 2022; 22:80-86. [PMID: 35007273 DOI: 10.1227/ons.0000000000000005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Minimally invasive surgical techniques have reinvigorated the role of surgical options for spontaneous intracranial hematomas; however, they are limited by the lack of real-time feedback on the extent of hematoma evacuation. OBJECTIVE To describe the development of a MRI-guided catheter-based aspiration system, the ClearPoint Pursuit Neuroaspiration Device (ClearPoint Neuro) and validation in phantom models. METHODS In this preclinical experimental trial, 8 phantom brains with skull models were created to simulate an intracranial hematoma with 2 clot sizes, 30 cc (small clot) and 60 cc (large clot). After registration, the aspiration catheter (Pursuit device) was aligned to the desired planned trajectory. The aspiration of the clot was performed under real-time MRI scan in 3 orthogonal views. The primary end point was reduction of the clot volume to less than 15 cc or 70% of the original clot volume. RESULTS Successful completion of clot evacuation was achieved in all models. The average postaspiration clot volume was 9.5 cc (8.7 cc for small clots and 10.2 cc for large clots). The average percentage reduction of clot volume was 76.3% (range 58.7%-85.2%). The average total procedure time (from frame registration to final postaspiration clot assessment) was 50 min. The average aspiration time was 6.9 min. CONCLUSION This preclinical trial confirms the feasibility and efficacy of MRI-guided aspiration under real-time image guidance in simulation models for intracranial hematoma. Clinical use of the system in patients would further validate its efficacy and safety.
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Affiliation(s)
- Devi P Patra
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Matthew E Welz
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Evelyn L Turcotte
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Kamal Vij
- ClearPoint Neuro, Inc., Irvine, California, USA
| | - Max Daly
- ClearPoint Neuro, Inc., Irvine, California, USA
| | | | | | - Yuxiang Zhou
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
| | - Brooke Halpin
- School of Life Sciences, Arizona State University, Tempe, Arizona, USA
| | | | - Arjun Syal
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
- Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA
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17
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Koh EJ, Golubovsky JL, Rammo R, Momin A, Walter B, Fernandez HH, Machado A, Nagel SJ. Estimating the Risk of Deep Brain Stimulation in the Modern Era: 2008 to 2020. Oper Neurosurg (Hagerstown) 2021; 21:277-290. [PMID: 34392372 DOI: 10.1093/ons/opab261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly. OBJECTIVE To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery. METHODS PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients. RESULTS The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%. CONCLUSION This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.
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Affiliation(s)
- Eun Jeong Koh
- Department of Neurosurgery, Jeonbuk National University Medical School, Jeonju, Jeonbuk, Republic of Korea
| | - Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arbaz Momin
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Benjamin Walter
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hubert H Fernandez
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
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18
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Segar DJ, Tata N, Harary M, Hayes MT, Cosgrove GR. Asleep deep brain stimulation with intraoperative magnetic resonance guidance: a single-institution experience. J Neurosurg 2021; 136:699-708. [PMID: 34359029 DOI: 10.3171/2020.12.jns202572] [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: 07/06/2020] [Accepted: 12/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is traditionally performed on an awake patient with intraoperative recordings and test stimulation. DBS performed under general anesthesia with intraoperative MRI (iMRI) has demonstrated high target accuracy, reduced operative time, direct confirmation of target placement, and the ability to place electrodes without cessation of medications. The authors describe their initial experience with using iMRI to perform asleep DBS and discuss the procedural and radiological outcomes of this procedure. METHODS All DBS electrodes were implanted under general anesthesia by a single surgeon by using a neuronavigation system with 3-T iMRI guidance. Clinical outcomes, operative duration, complications, and accuracy were retrospectively analyzed. RESULTS In total, 103 patients treated from 2015 to 2019 were included, and all but 1 patient underwent bilateral implantation. Indications included Parkinson's disease (PD) (65% of patients), essential tremor (ET) (29%), dystonia (5%), and refractory epilepsy (1%). Targets included the globus pallidus pars internus (12.62% of patients), subthalamic nucleus (56.31%), ventral intermedius nucleus of the thalamus (30%), and anterior nucleus of the thalamus (1%). Technically accurate lead placement (radial error ≤ 1 mm) was obtained for 98% of leads, with a mean (95% CI) radial error of 0.50 (0.46-0.54) mm; all leads were placed with a single pass. Predicted radial error was an excellent predictor of real radial error, underestimating real error by only a mean (95% CI) of 0.16 (0.12-0.20) mm. Accuracy remained high irrespective of surgeon experience, but procedure time decreased significantly with increasing institutional and surgeon experience (p = 0.007), with a mean procedure duration of 3.65 hours. Complications included 1 case of intracranial hemorrhage (asymptomatic) and 1 case of venous infarction (symptomatic), and 2 patients had infection at the internal pulse generator site. The mean ± SD voltage was 2.92 ± 0.83 V bilaterally at 1-year follow-up. Analysis of long-term clinical efficacy demonstrated consistent postoperative improvement in clinical symptoms, as well as decreased drug doses across all indications and follow-up time points, including mean decrease in levodopa-equivalent daily dose by 53.57% (p < 0.0001) in PD patients and mean decrease in primidone dose by 61.33% (p < 0.032) in ET patients at 1-year follow-up. CONCLUSIONS A total of 205 leads were placed in 103 patients by a single surgeon under iMRI guidance with few operative complications. Operative time trended downward with increasing institutional experience, and technical accuracy of radiographic lead placement was consistently high. Asleep DBS implantation with iMRI appears to be a safe and effective alternative to standard awake procedures.
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Affiliation(s)
| | - Nalini Tata
- Departments of1Neurosurgery and.,4Department of Neurosurgery, UCLA, Los Angeles, California
| | - Maya Harary
- Departments of1Neurosurgery and.,3Northwestern Feinberg School of Medicine, Chicago, Illinois; and
| | - Michael T Hayes
- 2Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Sammartino F, Taylor P, Chen G, Reynolds RC, Glen D, Krishna V. Functional Neuroimaging During Asleep DBS Surgery: A Proof of Concept Study. Front Neurol 2021; 12:659002. [PMID: 34262518 PMCID: PMC8273165 DOI: 10.3389/fneur.2021.659002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022] Open
Abstract
Object: A real-time functional magnetic resonance imaging (fMRI) feedback during ventral intermediate nucleus (VIM) deep brain stimulation (DBS) under general anesthesia (or “asleep” DBS) does not exist. We hypothesized that it was feasible to acquire a reliable and responsive fMRI during asleep VIM DBS surgery. Methods: We prospectively enrolled 10 consecutive patients who underwent asleep DBS for the treatment of medication-refractory essential tremor. Under general anesthesia, we acquired resting-state functional MRI immediately before and after the cannula insertion. Reliability was determined by a temporal signal-to-noise-ratio >100. Responsiveness was determined based on the fMRI signal change upon insertion of the cannula to the VIM. Results: It was feasible to acquire reliable fMRI during asleep DBS surgery. The fMRI signal was responsive to the brain cannula insertion, revealing a reduction in the tremor network's functional connectivity, which did not reach statistical significance in the group analysis. Conclusions: It is feasible to acquire a reliable and responsive fMRI signal during asleep DBS. The acquisition steps and the preprocessing pipeline developed in these experiments will be useful for future investigations to develop fMRI-based feedback for asleep DBS surgery.
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Affiliation(s)
- Francesco Sammartino
- Department of Neurosurgery, The Ohio State University, Columbus, OH, United States
| | - Paul Taylor
- Scientific and Statistical Computing Core, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Gang Chen
- Scientific and Statistical Computing Core, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Richard C Reynolds
- Scientific and Statistical Computing Core, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Daniel Glen
- Scientific and Statistical Computing Core, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Vibhor Krishna
- Department of Neurosurgery, The Ohio State University, Columbus, OH, United States
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20
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Moran C, Sarangmat N, Gerard CS, Barua N, Ashida R, Woolley M, Pietrzyk M, Gill SS. Two Hundred Twenty-Six Consecutive Deep Brain Stimulation Electrodes Placed Using an "Asleep" Technique and the Neuro|MateTM Robot for the Treatment of Movement Disorders. Oper Neurosurg (Hagerstown) 2021; 19:530-538. [PMID: 32629477 DOI: 10.1093/ons/opaa176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 04/15/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Robotics in neurosurgery has demonstrated widening indications and rapid growth in recent years. Robotic precision and reproducibility are especially pertinent to the field of functional neurosurgery. Deep brain stimulation (DBS) requires accurate placement of electrodes in order to maximize efficacy and minimize side effects. In addition, asleep techniques demand clear target visualization and immediate on-table verification of accuracy. OBJECTIVE To describe the surgical technique of asleep DBS surgery using the Neuro|MateTM Robot (Renishaw plc, Wotton-under-Edge, United Kingdom) and examine the accuracy of DBS lead placement in the subthalamic nucleus (STN) for the treatment of movement disorders. METHODS A single-center retrospective review of 113 patients who underwent bilateral STN/Zona Incerta electrode placement was performed. Accuracy of implantation was assessed using 5 measurements, Euclidian distance, radial error, depth error, angular error, and shift error. RESULTS A total of 226 planned vs actual electrode placements were analyzed. The mean 3-dimensional vector error calculated for 226 trajectories was 0.78 +/- 0.37 mm. The mean radial displacement off planned trajectory was 0.6 +/- 0.33 mm. The mean depth error, angular error, and shift error was 0.4 +/- 0.35 mm, 0.4 degrees, and 0.3 mm, respectively. CONCLUSION This report details our institution's method for DBS lead placement in patients under general anaesthesia using anatomical targeting without microelectrode recordings or intraoperative test stimulation for the treatment of movement disorders. This is the largest reported dataset of accuracy results in DBS surgery performed asleep. This novel robot-assisted operative technique results in sub-millimeter accuracy in DBS electrode placement.
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Affiliation(s)
- Catherine Moran
- Functional Neurosurgery Group, Clinical Neurosciences, University of Bristol, Bristol, United Kingdom.,Department of Neurosurgery, North Bristol Trust, Westbury-on-Trym, United Kingdom
| | - Nagaraja Sarangmat
- Department of Neurology, North Bristol Trust, Westbury-on-Trym, United Kingdom
| | - Carter S Gerard
- Department of Neurosurgery, North Bristol Trust, Westbury-on-Trym, United Kingdom
| | - Neil Barua
- Department of Neurosurgery, North Bristol Trust, Westbury-on-Trym, United Kingdom
| | - Reiko Ashida
- Department of Neurosurgery, North Bristol Trust, Westbury-on-Trym, United Kingdom
| | - Max Woolley
- Functional Neurosurgery Group, Clinical Neurosciences, University of Bristol, Bristol, United Kingdom.,Neurological Products Division, Renishaw Plc, Wotton-under-Edge, United Kingdom
| | - Mariusz Pietrzyk
- Neurological Products Division, Renishaw Plc, Wotton-under-Edge, United Kingdom
| | - Steven S Gill
- Functional Neurosurgery Group, Clinical Neurosciences, University of Bristol, Bristol, United Kingdom.,Department of Neurosurgery, North Bristol Trust, Westbury-on-Trym, United Kingdom
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21
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Philipp LR, Matias CM, Thalheimer S, Mehta SH, Sharan A, Wu C. Robot-Assisted Stereotaxy Reduces Target Error: A Meta-Analysis and Meta-Regression of 6056 Trajectories. Neurosurgery 2021; 88:222-233. [PMID: 33045739 DOI: 10.1093/neuros/nyaa428] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The pursuit of improved accuracy for localization and electrode implantation in deep brain stimulation (DBS) and stereoelectroencephalography (sEEG) has fostered an abundance of disparate surgical/stereotactic practices. Specific practices/technologies directly modify implantation accuracy; however, no study has described their respective influence in multivariable context. OBJECTIVE To synthesize the known literature to statistically quantify factors affecting implantation accuracy. METHODS A systematic review and meta-analysis was conducted to determine the inverse-variance weighted pooled mean target error (MTE) of implanted electrodes among patients undergoing DBS or sEEG. MTE was defined as Euclidean distance between planned and final electrode tip. Meta-regression identified moderators of MTE in a multivariable-adjusted model. RESULTS A total of 37 eligible studies were identified from a search return of 2,901 potential articles (2002-2018) - 27 DBS and 10 sEEG. Random-effects pooled MTE = 1.91 mm (95% CI: 1.7-2.1) for DBS and 2.34 mm (95% CI: 2.1-2.6) for sEEG. Meta-regression identified study year, robot use, frame/frameless technique, and intraoperative electrophysiologic testing (iEPT) as significant multivariable-adjusted moderators of MTE (P < .0001, R2 = 0.63). Study year was associated with a 0.92-mm MTE reduction over the 16-yr study period (P = .0035), and robot use with a 0.79-mm decrease (P = .0019). Frameless technique was associated with a mean 0.50-mm (95% CI: 0.17-0.84) increase, and iEPT use with a 0.45-mm (95% CI: 0.10-0.80) increase in MTE. Registration method, imaging type, intraoperative imaging, target, and demographics were not significantly associated with MTE on multivariable analysis. CONCLUSION Robot assistance for stereotactic electrode implantation is independently associated with improved accuracy and reduced target error. This remains true regardless of other procedural factors, including frame-based vs frameless technique.
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Affiliation(s)
- Lucas R Philipp
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Caio M Matias
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Sara Thalheimer
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Shyle H Mehta
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Ashwini Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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22
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Moran CH, Pietrzyk M, Sarangmat N, Gerard CS, Barua N, Ashida R, Whone A, Szewczyk-Krolikowski K, Mooney L, Gill SS. Clinical Outcome of "Asleep" Deep Brain Stimulation for Parkinson Disease Using Robot-Assisted Delivery and Anatomic Targeting of the Subthalamic Nucleus: A Series of 152 Patients. Neurosurgery 2021; 88:165-173. [PMID: 32985669 DOI: 10.1093/neuros/nyaa367] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 06/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent advances in methods used for deep brain stimulation (DBS) include subthalamic nucleus electrode implantation in the "asleep" patient without the traditional use of microelectrode recordings or intraoperative test stimulation. OBJECTIVE To examine the clinical outcome of patients who have undergone "asleep" DBS for the treatment of Parkinson disease using robot-assisted electrode delivery. METHODS This is a retrospective review of clinical outcomes of 152 consecutive patients. Their outcomes at 1 yr postimplantation are reported; these include Unified Parkinson's Disease Rating Scale (UPDRS) assessment, Tinetti Mobility Test, Parkinson's Disease Questionnaire (PDQ)-39 quality of life assessment, Mattis Dementia Rating Scale, Beck Depression Inventory, and Beck Anxiety. We also report on a new parietal trajectory for electrode implantation. RESULTS A total of 152 patients underwent assessment at 1 yr. UPDRS III improved from 39 to 20.5 (47%, P < .001). The total UPDRS score improved from 67.6 to 36.4 (46%, P < .001). UPDRS II scores improved from 18.9 to 10.5 (44%, P < .001) and UPDRS IV scores improved from 7.1 to 3.6 (49%, P < .001). There was a significant reduction in levodopa equivalent daily dose after surgery (mean: 35%, P < .001). PDQ-39 summary index improved by a mean of 7.1 points. There was no significant difference found in clinical outcomes between the frontal and parietal approaches. CONCLUSION "Asleep" robot-assisted DBS of the subthalamic nucleus demonstrates comparable outcomes with traditional techniques in the treatment of Parkinson disease.
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Affiliation(s)
- Catherine H Moran
- Department of Neurosurgery, Tallaght University Hospital, Dublin, Ireland
| | - Mariusz Pietrzyk
- Neurological Applications Division, Renishaw PlC, Wooton-under-Edge, United Kinrgdom
| | - Nagaraja Sarangmat
- Department of Neurology, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - Carter S Gerard
- Department of Neurosurgery, Swedish Medical Center, Seattle, Washington
| | - Neil Barua
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - Reiko Ashida
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - Alan Whone
- Department of Neurology, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | | | - Lucy Mooney
- Department of Neurology, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - Steven S Gill
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
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23
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Brock AA, Kundu B, Rolston JD. Asleep Deep Brain Stimulator Placement in the Intraoperative Magnetic Resonance Imaging System Hybrid Operating Suite: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E217-E218. [PMID: 33294935 PMCID: PMC8133329 DOI: 10.1093/ons/opaa337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/12/2020] [Indexed: 11/12/2022] Open
Abstract
Asleep, image-guided deep brain stimulation (DBS) placement is rapidly gaining popularity because it offers greater patient comfort and comparable accuracy with frame-based methods using microelectrode recording.1 In this video, we demonstrate our protocol to use the frameless, stereotactic ClearPoint system (MRI Interventions Inc, Irvine, California) to place DBS electrodes within an intraoperative magnetic resonance imaging hybrid operating suite (IMRIS; Deerfield Imaging Inc, Minnetonka, Minnesota).1-4 This system uses a skull-mounted aiming device coupled with sequential, intraoperative magnetic resonance imaging guidance to direct DBS lead placement to subcortical targets.2,5 Importantly, this method allows the patient to remain asleep during the operation and does not require medication holidays or additional microelectrode recording equipment. The literature indicates it has comparable accuracy1,6 and outcomes2 with the awake method. We demonstrate this technique with the case of a patient with Parkinson disease who required lead placement in the bilateral subthalamic nuclei.7-9 The patient consented to the procedure and publication. Patient positioning, draping nuances, initial indirect targeting, and final direct targeting are demonstrated. Risks of the operation include a risk of hemorrhage, hardware failure, and infection.10 DBS is currently an underutilized treatment option for patients with Parkinson disease.11 Offering the asleep option may be more tolerable for many patients who are wary of awake surgery.
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Affiliation(s)
- Andrea A Brock
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - John D Rolston
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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24
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Costanzo MR, Javaheri S, Ponikowski P, Oldenburg O, Augostini R, Goldberg LR, Stellbrink C, Fox H, Schwartz AR, Gupta S, McKane S, Meyer TE, Abraham WT. Transvenous Phrenic Nerve Stimulation for Treatment of Central Sleep Apnea: Five-Year Safety and Efficacy Outcomes. Nat Sci Sleep 2021; 13:515-526. [PMID: 33953626 PMCID: PMC8092633 DOI: 10.2147/nss.s300713] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/09/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The remedē System Pivotal Trial was a prospective, multi-center, randomized trial demonstrating transvenous phrenic nerve stimulation (TPNS) therapy is safe and effectively treats central sleep apnea (CSA) and improves sleep architecture and daytime sleepiness. Subsequently, the remedē System was approved by FDA in 2017. As a condition of approval, the Post Approval Study (PAS) collected clinical evidence regarding long-term safety and effectiveness in adults with moderate to severe CSA through five years post implant. METHODS Patients remaining in the Pivotal Trial at the time of FDA approval were invited to enroll in the PAS and consented to undergo sleep studies (scored by a central laboratory), complete the Epworth Sleepiness Scale (ESS) questionnaire to assess daytime sleepiness, and safety assessment. All subjects (treatment and former control group) receiving active therapy were pooled; data from both trials were combined for analysis. RESULTS Fifty-three of the original 151 Pivotal Trial patients consented to participate in the PAS and 52 completed the 5-year visit. Following TPNS therapy, the apnea-hypopnea index (AHI), central-apnea index (CAI), arousal index, oxygen desaturation index, and sleep architecture showed sustained improvements. Comparing 5 years to baseline, AHI and CAI decreased significantly (AHI baseline median 46 events/hour vs 17 at 5 years; CAI baseline median 23 events/hour vs 1 at 5 years), though residual hypopneas were present. In parallel, the arousal index, oxygen desaturation index and sleep architecture improved. The ESS improved by a statistically significant median reduction of 3 points at 5 years. Serious adverse events related to implant procedure, device or delivered therapy were reported by 14% of patients which include 16 (9%) patients who underwent a pulse generator reposition or lead revision (primarily in the first year). None of the events caused long-term harm. No unanticipated adverse device effects or related deaths occurred through 5 years. CONCLUSION Long-term TPNS safely improves CSA, sleep architecture and daytime sleepiness through 5 years post implant. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01816776.
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Affiliation(s)
| | - Shahrokh Javaheri
- Bethesda North Hospital, Cincinnati, OH, USA.,The Ohio State University, Columbus, OH, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wroclaw, Poland
| | - Olaf Oldenburg
- Ludgerus-Kliniken Münster, Clemens Hospital, Münster, Germany
| | | | - Lee R Goldberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Henrik Fox
- Clinic for General and Interventional Cardiology Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Alan R Schwartz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sanjaya Gupta
- University of Missouri-Kansas City School of Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
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25
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Richardson RM, Bankiewicz KS, Christine CW, Van Laar AD, Gross RE, Lonser R, Factor SA, Kostyk SK, Kells AP, Ravina B, Larson PS. Data-driven evolution of neurosurgical gene therapy delivery in Parkinson's disease. J Neurol Neurosurg Psychiatry 2020; 91:1210-1218. [PMID: 32732384 PMCID: PMC7569395 DOI: 10.1136/jnnp-2020-322904] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/28/2020] [Accepted: 06/11/2020] [Indexed: 12/11/2022]
Abstract
Loss of nigrostriatal dopaminergic projection neurons is a key pathology in Parkinson's disease, leading to abnormal function of basal ganglia motor circuits and the accompanying characteristic motor features. A number of intraparenchymally delivered gene therapies designed to modify underlying disease and/or improve clinical symptoms have shown promise in preclinical studies and subsequently were evaluated in clinical trials. Here we review the challenges with surgical delivery of gene therapy vectors that limited therapeutic outcomes in these trials, particularly the lack of real-time monitoring of vector administration. These challenges have recently been addressed during the evolution of novel techniques for vector delivery that include the use of intraoperative MRI. The preclinical development of these techniques are described in relation to recent clinical translation in an adeno-associated virus serotype 2-mediated human aromatic L-amino acid decarboxylase gene therapy development programme. This new paradigm allows visualisation of the accuracy and adequacy of viral vector delivery within target structures, enabling intertrial modifications in surgical approaches, cannula design, vector volumes and dosing. The rapid, data-driven evolution of these procedures is unique and has led to improved vector delivery.
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Affiliation(s)
- R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA .,Harvard Medical School, Boston, Massachusetts, USA
| | - Krystof S Bankiewicz
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Chadwick W Christine
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Amber D Van Laar
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Brain Neurotherapy Bio, Inc, Columbus, Ohio, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Russell Lonser
- Department of Neurological Surgery, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Stewart A Factor
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Sandra K Kostyk
- Departments of Neuroscience and Neurology, Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Bernard Ravina
- Praxis Precision Medicines, Inc, Cambridge, Massachusetts, USA
| | - Paul S Larson
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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26
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Gravbrot N, Saranathan M, Nagae LM, Becker J, Kasoff WS. Safety Profile of Infinity Deep Brain Stimulation Electrode Placement in a 1.5T Interventional MRI Suite: Consecutive Single-Institution Case Series. AJNR Am J Neuroradiol 2020; 41:2257-2262. [PMID: 33004341 DOI: 10.3174/ajnr.a6776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/15/2020] [Indexed: 11/07/2022]
Abstract
"Asleep" deep brain stimulation using general anesthesia and intraoperative MR imaging guidance is considered "off-label" use by current FDA guidelines but is widely used in neurosurgical practice, and excellent safety has been demonstrated using first-generation, omnidirectional electrodes. Safety data for second-generation, directional electrodes in the interventional MR imaging environment have not yet been published. Herein, we report 34 cases of asleep deep brain stimulation using second-generation, directional electrodes in an interventional MR imaging suite at a single institution. Procedural complications and imaging data are described. All patients underwent postoperative MR imaging with fully implanted ("internalized") electrodes after scalp closure; 4 patients also underwent MR imaging with "externalized" electrodes before scalp closure. No MR imaging-related complications were observed, and procedural complication rates were comparable to prior series. This suggests that the use of second-generation, directional electrodes in the interventional MR imaging environment appears to be safe when following manufacturer-published imaging guidelines.
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Affiliation(s)
- N Gravbrot
- Department of Neurosurgery (N.G., M.S., J.B., W.S.K.)
| | - M Saranathan
- Department of Neurosurgery (N.G., M.S., J.B., W.S.K.).,Medical Imaging (M.S., L.M.N., J.B.), University of Arizona School of Medicine, Tucson, Arizona
| | - L M Nagae
- Medical Imaging (M.S., L.M.N., J.B.), University of Arizona School of Medicine, Tucson, Arizona
| | - J Becker
- Department of Neurosurgery (N.G., M.S., J.B., W.S.K.).,Medical Imaging (M.S., L.M.N., J.B.), University of Arizona School of Medicine, Tucson, Arizona
| | - W S Kasoff
- Department of Neurosurgery (N.G., M.S., J.B., W.S.K.)
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27
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Sharma VD, Patel M, Miocinovic S. Surgical Treatment of Parkinson's Disease: Devices and Lesion Approaches. Neurotherapeutics 2020; 17:1525-1538. [PMID: 33118132 PMCID: PMC7851282 DOI: 10.1007/s13311-020-00939-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 10/23/2022] Open
Abstract
Surgical treatments have transformed the management of Parkinson's disease (PD). Therapeutic options available for the management of PD motor complications include deep brain stimulation (DBS), ablative or lesioning procedures (pallidotomy, thalamotomy, subthalamotomy), and dopaminergic medication infusion devices. The decision to pursue these advanced treatment options is typically done by a multidisciplinary team by considering factors such as the patient's clinical characteristics, efficacy, ease of use, and risks of therapy with a goal to improve PD symptoms and quality of life. DBS has become the most widely used surgical therapy, although there is a re-emergence of interest in ablative procedures with the introduction of MR-guided focused ultrasound. In this article, we review DBS and lesioning procedures for PD, including indications, selection process, and management strategies.
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Affiliation(s)
- Vibhash D Sharma
- Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Blvd, MS 3042, Kansas City, KS, 66160, USA.
| | - Margi Patel
- Department of Neurology, Emory University, Atlanta, GA, USA
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28
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Gonzalez-Escamilla G, Muthuraman M, Ciolac D, Coenen VA, Schnitzler A, Groppa S. Neuroimaging and electrophysiology meet invasive neurostimulation for causal interrogations and modulations of brain states. Neuroimage 2020; 220:117144. [DOI: 10.1016/j.neuroimage.2020.117144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/22/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022] Open
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29
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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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30
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Automated detection of subthalamic nucleus in deep brain stimulation surgery for Parkinson’s disease using microelectrode recordings and wavelet packet features. J Neurosci Methods 2020; 343:108826. [DOI: 10.1016/j.jneumeth.2020.108826] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/22/2020] [Indexed: 01/02/2023]
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31
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Martini ML, Oermann EK, Opie NL, Panov F, Oxley T, Yaeger K. Sensor Modalities for Brain-Computer Interface Technology: A Comprehensive Literature Review. Neurosurgery 2020; 86:E108-E117. [PMID: 31361011 DOI: 10.1093/neuros/nyz286] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/04/2019] [Indexed: 12/23/2022] Open
Abstract
Brain-computer interface (BCI) technology is rapidly developing and changing the paradigm of neurorestoration by linking cortical activity with control of an external effector to provide patients with tangible improvements in their ability to interact with the environment. The sensor component of a BCI circuit dictates the resolution of brain pattern recognition and therefore plays an integral role in the technology. Several sensor modalities are currently in use for BCI applications and are broadly either electrode-based or functional neuroimaging-based. Sensors vary in their inherent spatial and temporal resolutions, as well as in practical aspects such as invasiveness, portability, and maintenance. Hybrid BCI systems with multimodal sensory inputs represent a promising development in the field allowing for complimentary function. Artificial intelligence and deep learning algorithms have been applied to BCI systems to achieve faster and more accurate classifications of sensory input and improve user performance in various tasks. Neurofeedback is an important advancement in the field that has been implemented in several types of BCI systems by showing users a real-time display of their recorded brain activity during a task to facilitate their control over their own cortical activity. In this way, neurofeedback has improved BCI classification and enhanced user control over BCI output. Taken together, BCI systems have progressed significantly in recent years in terms of accuracy, speed, and communication. Understanding the sensory components of a BCI is essential for neurosurgeons and clinicians as they help advance this technology in the clinical setting.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York
| | - Eric Karl Oermann
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York
| | - Nicholas L Opie
- Vascular Bionics Laboratory, Department of Medicine, Melbourne University, Melbourne, Australia
| | - Fedor Panov
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York
| | - Thomas Oxley
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York.,Vascular Bionics Laboratory, Department of Medicine, Melbourne University, Melbourne, Australia
| | - Kurt Yaeger
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York
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32
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Li G, Patel NA, Burdette EC, Pilitsis JG, Su H, Fischer GS. A Fully Actuated Robotic Assistant for MRI-Guided Precision Conformal Ablation of Brain Tumors. IEEE/ASME TRANSACTIONS ON MECHATRONICS : A JOINT PUBLICATION OF THE IEEE INDUSTRIAL ELECTRONICS SOCIETY AND THE ASME DYNAMIC SYSTEMS AND CONTROL DIVISION 2020; 26:255-266. [PMID: 33994771 PMCID: PMC8117662 DOI: 10.1109/tmech.2020.3012903] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This paper reports the development of a fully actuated robotic assistant for magnetic resonance imaging (MRI)-guided precision conformal ablation of brain tumors using an interstitial high intensity needle-based therapeutic ultrasound (NBTU) ablator probe. The robot is designed with an eight degree-of-freedom (DOF) remote center of motion (RCM) manipulator driven by piezoelectric actuators, five for aligning the ultrasound thermal ablator to the target lesions and three for inserting and orienting the ablator and its cannula to generate a desired ablation profile. The 8-DOF fully actuated robot can be operated in the scanner bore during imaging; thus, alleviating the need of moving the patient in or out of the scanner during the procedure, and therefore potentially reducing the procedure time and streamlining the workflow. The free space positioning accuracy of the system is evaluated with the OptiTrack motion capture system, demonstrating the root mean square (RMS) error of the tip position to be 1.11±0.43mm. The system targeting accuracy in MRI is assessed with phantom studies, indicating the RMS errors of the tip position to be 1.45±0.66mm and orientation to be 1.53±0.69°. The feasibility of the system to perform thermal ablation is validated through a preliminary ex-vivo tissue study with position error less than 4.3mm and orientation error less than 4.3°.
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Affiliation(s)
- Gang Li
- Automation and Interventional Medicine (AIM) Laboratory in the Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Niravkumar A. Patel
- Automation and Interventional Medicine (AIM) Laboratory in the Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | | | | | - Hao Su
- Department of Mechanical Engineering, City College, City University of New York, NY, USA
| | - Gregory S. Fischer
- Automation and Interventional Medicine (AIM) Laboratory in the Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
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33
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Hwang BY, Mampre D, Mills K, Courtney P, Kim MJ, Butala AA, Anderson WS. Non-staged bilateral Globus Pallidus Internus deep brain stimulation lead revision using intraoperative MRI: a case report and literature review. Br J Neurosurg 2020; 35:301-305. [PMID: 32648480 DOI: 10.1080/02688697.2020.1789556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) lead revision due to suboptimal therapy is common but there is no standardised protocol. We describe a novel technique using iMRI to perform concurrent new Globus Pallidus Internus (GPi) DBS lead implantation and old lead removal in a dystonia patient.Case-description: A 60-year-old woman with medication and neurotoxin-refractory isolated cervical dystonia underwent awake bilateral GPi DBS surgery with MER-guided lead implantation. She initially had a favourable response but later reported suboptimal benefit despite reprogramming. MRI demonstrated suboptimal lead placement and MRI-guided revision surgery under general anesthesia was planned. The goal was to place new leads superior and medial to the existing leads. Using a 1.5 T iMRI and the ClearPoint® NeuroNavigation system, new leads were placed through the existing burr holes, into the new targets with radial errors < 0.08mm bilaterally without crossing the old leads. The old leads were then removed and the new leads connected to the existing pulse generator. The patient tolerated the procedure well and had improved side-effect profile at all contacts at 1-month follow-up. CONCLUSIONS Non-staged iMRI-guided DBS revision surgery under general anesthesia is technically feasible and is an alternative strategy to a staged iMRI-guided revision surgery or an awake MER-guided revision surgery in select patients.
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Affiliation(s)
- Brian Y Hwang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David Mampre
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kelly Mills
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Pamala Courtney
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Min Jae Kim
- Department of Biomedical Engineering and Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ankur A Butala
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Piano C, Bove F, Mulas D, Bentivoglio AR, Cioni B, Tufo T. Frameless stereotaxy in subthalamic deep brain stimulation: 3-year clinical outcome. Neurol Sci 2020; 42:259-266. [PMID: 32638134 PMCID: PMC7819924 DOI: 10.1007/s10072-020-04561-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 07/02/2020] [Indexed: 11/24/2022]
Abstract
Background In most centers, the surgery of deep brain stimulation (DBS) is performed using a stereotactic frame. Compared with frame-based technique, frameless stereotaxy reduces the duration of surgical procedure and patient’s discomfort, with lead placing accuracy equivalent after the learning curve. Although several studies have investigated the targeting accuracy of this technique, only a few studies reported clinical outcomes, with data of short-term follow-up. Objective To assess clinical efficacy and safety of frameless bilateral subthalamic nucleus (STN) DBS in Parkinson’s disease (PD) patients at 1- and 3-year follow-up. Methods Consecutive PD patients who underwent bilateral STN-DBS with a manual adjustable frameless system were included in the study. The data were collected retrospectively. Results Eighteen PD patients underwent bilateral STN-DBS implant and were included in the study. All patients completed 1-year observation and ten of them completed 3-year observation. At 1-year follow-up, motor efficacy of STN stimulation in off-med condition was of 30.1% (P = 0.003) and at 3-year follow-up was of 36.3%, compared with off-stim condition at 3-year follow-up (P = 0.005). Dopaminergic drugs were significantly reduced by 31.2% 1 year after the intervention (P = 0.003) and 31.7% 3 years after the intervention (P = 0.04). No serious adverse events occurred during surgery. Conclusions Frameless stereotaxy is an effective and safe technique for DBS surgery at 1- and 3-year follow-up, with great advantages for patients’ discomfort during surgery.
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Affiliation(s)
- Carla Piano
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Francesco Bove
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Delia Mulas
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy.,Institute of Neurology, Mater Olbia Hospital, Olbia, Italy
| | - Anna Rita Bentivoglio
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Beatrice Cioni
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Tufo
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Gravbrot N, Burket A, Saranathan M, Kasoff WS. Asleep Deep Brain Stimulation of the Nucleus Ventralis Intermedius for Essential Tremor Using Indirect Targeting and Interventional Magnetic Resonance Imaging: Single-Institution Case Series. Mov Disord Clin Pract 2020; 7:521-530. [PMID: 32626797 PMCID: PMC7328410 DOI: 10.1002/mdc3.12955] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/15/2020] [Accepted: 03/30/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Literature on asleep deep brain stimulation (DBS) of the ventralis intermedius (Vim) nucleus in essential tremor is relatively sparse. Furthermore, controversy exists as to whether indirect ("consensus" or "atlas-based") targeting of the Vim requires physiologic adjustment for effective clinical outcomes in DBS surgery. OBJECTIVES The objective of this study was to evaluate the clinical results of asleep Vim DBS using indirect coordinates and real-time interventional magnetic resonance imaging guidance. METHODS Retrospective review of a prospectively collected database was performed to identify patients with essential tremor undergoing asleep Vim DBS using interventional magnetic resonance imaging guidance. Stereotactic and clinical outcomes were abstracted and analyzed using descriptive statistics. RESULTS A total of 12 consecutive patients were identified, all of whom were available for 6-month clinical follow-up. Stereotactic (radial) error was 0.5 ± 0.2 mm on the left and 0.5 ± 0.3 mm on the right. Fahn-Tolosa-Marin tremor scores in the treated limb(s) decreased by 71.2% ± 31.0% (P = 0.0088), The Essential Tremor Rating Assessment Scale activities of daily living improved by 74.9% ± 23.7% (P < 0.0001), and The Essential Tremor Rating Assessment Scale performance improved by 64.3 ± 16.2% (P = 0.0004). Surgical complications were mild and generally transient. Stimulation-related side effects were similar to those reported in historical series of awake Vim DBS. CONCLUSIONS Asleep Vim DBS using indirect targeting and interventional magnetic resonance imaging-guided placement is safe and effective, with 6-month clinical results similar to those achieved with awake placement. These data support the use of asleep surgery in essential tremor and represent a baseline for comparison with future studies using more advanced targeting techniques.
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Affiliation(s)
- Nicholas Gravbrot
- Department of NeurosurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Aaron Burket
- Department of NeurosurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Manojkumar Saranathan
- Department of Medical ImagingUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Willard S. Kasoff
- Department of NeurosurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
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Ball TJ, John KD, Donovan AM, Neimat JS. Deep Brain Stimulation Lead Implantation Using a Customized Rapidly Manufactured Stereotactic Fixture with Submillimetric Euclidean Accuracy. Stereotact Funct Neurosurg 2020; 98:248-255. [PMID: 32485726 DOI: 10.1159/000506959] [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: 06/25/2019] [Accepted: 02/27/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND The microTargetingTM MicrotableTM Platform is a novel stereotactic system that can be more rapidly fabricated than currently available 3D-printed alternatives. We present the first case series of patients who underwent deep brain stimulation (DBS) surgery guided by this platform and demonstrate its in vivo accuracy. METHODS Ten patients underwent DBS at a single institution by the senior author and 15 leads were placed. The mean age was 69.1 years; four were female. The ventralis intermedius nucleus was targeted for patients with essential tremor and the subthalamic nucleus was targeted for patients with Parkinson's disease. RESULTS Nine DBS leads in 6 patients were appropriately imaged to enable measurement of accuracy. The mean Euclidean electrode placement error (EPE) was 0.97 ± 0.37 mm, and the mean radial error was 0.80 ± 0.41 mm (n = 9). In the subset of CT scans performed greater than 1 month postoperatively (n = 3), the mean Euclidean EPE was 0.75 ± 0.17 mm and the mean radial error was 0.69 ± 0.17 mm. There were no surgical complications. CONCLUSION The MicrotableTM platform is capable of submillimetric accuracy in patients undergoing stereotactic surgery. It has achieved clinical efficacy in our patients without surgical complications and has demonstrated the potential for superior accuracy compared to both traditional stereotactic frames and other common frameless systems.
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Affiliation(s)
- Tyler J Ball
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Kevin D John
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Andrew M Donovan
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Joseph S Neimat
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA,
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Abstract
Deep brain stimulation (DBS) has become an established therapeutic tool for treating patients with Parkinson's disease (PD) who have troublesome motor fluctuations and dyskinesias refractory to best medical therapy. In addition to its proven efficacy in patients with late PD, the EARLYSTIM trial not only demonstrated the efficacy of DBS in patients with early motor complications but also showed that it did not lose its therapeutic efficacy as the years passed by. However, like all other therapies for PD, DBS is not offered to patients either as a cure for this disease nor is it expected to stop the progression of the neurodegenerative process underlying PD; these important issues need to be highlighted to patients who are considering this therapy. This article aims to provide an introduction to residents or trainees starting a career in movement disorders of the technical aspects of this therapy and the evidence base for its use. For the latter objective, PUBMED was searched from 1946 to 2017 combining the search terms "deep brain stimulation" and "Parkinson's disease" looking for studies demonstrating the efficacy of this therapy in PD. Inclusion criteria included studies that involved more than 20 patients with a physician confirmed diagnosis of PD and a follow-up of greater than or equal to at least 12 months. The findings from those studies on motor symptoms, medication requirements, quality of life, and independence in activities of daily living in PD patients are summarized and presented in tabulated form in this paper at the end.
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Affiliation(s)
- Naveed Malek
- Department of Neurology, Ipswich Hospital NHS Trust, United Kingdom
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Bezchlibnyk YB, Sharma VD, Naik KB, Isbaine F, Gale JT, Cheng J, Triche SD, Miocinovic S, Buetefisch CM, Willie JT, Boulis NM, Factor SA, Wichmann T, DeLong MR, Gross RE. Clinical outcomes of globus pallidus deep brain stimulation for Parkinson disease: a comparison of intraoperative MRI- and MER-guided lead placement. J Neurosurg 2020; 134:1072-1082. [PMID: 32114534 DOI: 10.3171/2019.12.jns192010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) lead placement is increasingly performed with the patient under general anesthesia by surgeons using intraoperative MRI (iMRI) guidance without microelectrode recording (MER) or macrostimulation. The authors assessed the accuracy of lead placement, safety, and motor outcomes in patients with Parkinson disease (PD) undergoing DBS lead placement into the globus pallidus internus (GPi) using iMRI or MER guidance. METHODS The authors identified all patients with PD who underwent either MER- or iMRI-guided GPi-DBS lead placement at Emory University between July 2007 and August 2016. Lead placement accuracy and adverse events were determined for all patients. Clinical outcomes were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) part III motor scores for patients completing 12 months of follow-up. The authors also assessed the levodopa-equivalent daily dose (LEDD) and stimulation parameters. RESULTS Seventy-seven patients were identified (MER, n = 28; iMRI, n = 49), in whom 131 leads were placed. The stereotactic accuracy of the surgical procedure with respect to the planned lead location was 1.94 ± 0.21 mm (mean ± SEM) (95% CI 1.54-2.34) with frame-based MER and 0.84 ± 0.007 mm (95% CI 0.69-0.98) with iMRI. The rate of serious complications was similar, at 6.9% for MER-guided DBS lead placement and 9.4% for iMRI-guided DBS lead placement (RR 0.71 [95% CI 0.13%-3.9%]; p = 0.695). Fifty-seven patients were included in clinical outcome analyses (MER, n = 16; iMRI, n = 41). Both groups had similar characteristics at baseline, although patients undergoing MER-guided DBS had a lower response on their baseline levodopa challenge (44.8% ± 5.4% [95% CI 33.2%-56.4%] vs 61.6% ± 2.1% [95% CI 57.4%-65.8%]; t = 3.558, p = 0.001). Greater improvement was seen following iMRI-guided lead placement (43.2% ± 3.5% [95% CI 36.2%-50.3%]) versus MER-guided lead placement (25.5% ± 6.7% [95% CI 11.1%-39.8%]; F = 5.835, p = 0.019). When UPDRS III motor scores were assessed only in the contralateral hemibody (per-lead analyses), the improvements remained significantly different (37.1% ± 7.2% [95% CI 22.2%-51.9%] and 50.0% ± 3.5% [95% CI 43.1%-56.9%] for MER- and iMRI-guided DBS lead placement, respectively). Both groups exhibited similar reductions in LEDDs (21.2% and 20.9%, respectively; F = 0.221, p = 0.640). The locations of all active contacts and the 2D radial distance from these to consensus coordinates for GPi-DBS lead placement (x, ±20; y, +2; and z, -4) did not differ statistically by type of surgery. CONCLUSIONS iMRI-guided GPi-DBS lead placement in PD patients was associated with significant improvement in clinical outcomes, comparable to those observed following MER-guided DBS lead placement. Furthermore, iMRI-guided DBS implantation produced a similar safety profile to that of the MER-guided procedure. As such, iMRI guidance is an alternative to MER guidance for patients undergoing GPi-DBS implantation for PD.
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Affiliation(s)
- Yarema B Bezchlibnyk
- 1Department of Neurosurgery and Brain Repair, Morsani School of Medicine, University of South Florida, Tampa, Florida.,2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Vibhash D Sharma
- 3Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas.,4Department of Neurology, Emory University School of Medicine
| | - Kushal B Naik
- 5Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, and
| | - Faical Isbaine
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - John T Gale
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer Cheng
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,6Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | | | | | - Jon T Willie
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,4Department of Neurology, Emory University School of Medicine
| | - Nicholas M Boulis
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Thomas Wichmann
- 4Department of Neurology, Emory University School of Medicine
| | - Mahlon R DeLong
- 4Department of Neurology, Emory University School of Medicine
| | - Robert E Gross
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,4Department of Neurology, Emory University School of Medicine
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Preston C, Alvarez AM, Barragan A, Becker J, Kasoff WS, Witte RS. High resolution transcranial acoustoelectric imaging of current densities from a directional deep brain stimulator. J Neural Eng 2020; 17:016074. [PMID: 31978914 PMCID: PMC7446234 DOI: 10.1088/1741-2552/ab6fc3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE New innovations in deep brain stimulation (DBS) enable directional current steering-allowing more precise electrical stimulation of the targeted brain structures for Parkinson's disease, essential tremor and other neurological disorders. While intra-operative navigation through MRI or CT approaches millimeter accuracy for placing the DBS leads, no existing modality provides feedback of the currents as they spread from the contacts through the brain tissue. In this study, we investigate transcranial acoustoelectric imaging (tAEI) as a new modality to non-invasively image and characterize current produced from a directional DBS lead. tAEI uses ultrasound (US) to modulate tissue resistivity to generate detectable voltage signals proportional to the local currents. APPROACH An 8-channel directional DBS lead (Infinity 6172ANS, Abbott Inc) was inserted inside three adult human skulls submerged in 0.9% NaCl. A 2.5 MHz linear array delivered US pulses through the transtemporal window and focused near the contacts on the lead, while a custom amplifier and acquisition system recorded the acoustoelectric (AE) interaction used to generate images. MAIN RESULTS tAEI detected monopolar current with stimulation pulses as short as 100 µs with an SNR ranging from 10-27 dB when using safe US pressure (mechanical indices <0.78) and injected current of ~2 mA peak amplitude. Adjacent contacts were discernable along the length and within each ring of the lead with a mean radial separation between contacts of 2.10 and 1.34 mm, respectively. SIGNIFICANCE These results demonstrate the feasibility of tAEI for high resolution mapping of directional DBS currents using clinically-relevant stimulation parameters. This new modality may improve the accuracy for placing the DBS leads, guide calibration and programming, and monitor long-term performance of DBS for treatment of Parkinson's disease.
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Affiliation(s)
- Chet Preston
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States of America
| | - Alexander M Alvarez
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States of America
| | - Andres Barragan
- Department of Computer Science, University of Arizona, Tucson, AZ, United States of America
| | - Jennifer Becker
- Department of Medical Imaging, University of Arizona, Tucson, AZ, United States of America
| | - Willard S Kasoff
- Department of Surgery, University of Arizona, Tucson, AZ, United States of America
| | - Russell S Witte
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States of America
- Department of Medical Imaging, University of Arizona, Tucson, AZ, United States of America
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Luo M, Larson PS, Martin AJ, Miga MI. Accounting for Deformation in Deep Brain Stimulation Surgery With Models: Comparison to Interventional Magnetic Resonance Imaging. IEEE Trans Biomed Eng 2020; 67:2934-2944. [PMID: 32078527 DOI: 10.1109/tbme.2020.2974102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The efficacy of deep brain stimulation (DBS) depends on electrode placement accuracy, which can be jeopardized by brain shift due to burr hole and dura opening during surgery. Brain shift violates assumed rigid alignment between preoperative image and intraoperative anatomy, negatively impacting therapy. OBJECTIVE This study presents a deformation-atlas biomechanical model-based approach to address shift. METHODS Six patients, who underwent interventional magnetic resonance (iMR) image-guided DBS burr hole surgery, were studied. A patient-specific model was employed under varying surgical conditions, generating a collection of possible intraoperative shift estimations or a 'deformation atlas.' An inverse problem was driven by sparse measurements derived from iMR to determine an optimal fit of solutions of the atlas. This fit was then used to obtain a volumetric deformation field, which was utilized to update preoperative MR and estimate shift at surgical target region localized on iMR. Model performance was examined by quantitatively comparing intraoperative subsurface measurements to their model-predicted counterparts, and qualitatively comparing iMR, preoperative MR, and model updated MR. A nonrigid image registration was introduced as a comparator. RESULTS Model-based approach reduced general parenchyma shift from 8.2 ± 2.2 to 2.7 ± 1.1 mm (∼66.8% correction), and produced updated MR with better agreement to iMR than that of preoperative MR. The average model estimated shift at target region was 1.2 mm. CONCLUSIONS This study demonstrates the feasibility of a model-based shift correction strategy in DBS surgery with only sparse data. SIGNIFICANCE The developed strategy has the potential to complement and/or enhance current clinical approaches in addressing shift.
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41
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Ponce FA. Intraoperative Magnetic Resonance Imaging and Computed Tomography. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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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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Chan AK, Chan AY, Lau D, Durcanova B, Miller CA, Larson PS, Starr PA, Mummaneni PV. Surgical management of camptocormia in Parkinson's disease: systematic review and meta-analysis. J Neurosurg 2019; 131:368-375. [PMID: 30215560 DOI: 10.3171/2018.4.jns173032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/02/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Camptocormia is a potentially debilitating condition in the progression of Parkinson's disease (PD). It is described as an abnormal forward flexion while standing that resolves when lying supine. Although the condition is relatively common, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, the authors systematically reviewed the current surgical management strategies for camptocormia. METHODS PubMed was queried for primary studies involving surgical intervention for camptocormia in PD patients. Studies were excluded if they described nonsurgical interventions, provided only descriptive data, or were case reports. Secondarily, data from studies describing deep brain stimulation (DBS) to the subthalamic nuclei were extracted for potential meta-analysis. Variables showing correlation to improvement in sagittal plane bending angle (i.e., the vertical angle caused by excessive kyphosis) were subjected to formal meta-analysis. RESULTS The query resulted in 9 studies detailing treatment of camptocormia: 1 study described repetitive trans-spinal magnetic stimulation (rTSMS), 7 studies described DBS, and 1 study described deformity surgery. Five studies were included for meta-analysis. The total number of patients was 66. The percentage of patients with over 50% decrease in sagittal plane imbalance with DBS was 36.4%. A duration of camptocormia of 2 years or less was predictive of better outcomes (OR 4.15). CONCLUSIONS Surgical options include transient, external spinal stimulation; DBS targeting the subthalamic nuclei; and spinal deformity surgery. Benefit from DBS stimulation was inconsistent. Spine surgery corrected spinal imbalance but was associated with a high complication rate.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Alvin Y Chan
- 2Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Darryl Lau
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Beata Durcanova
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Catherine A Miller
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Paul S Larson
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Philip A Starr
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
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Bullard AJ, Hutchison BC, Lee J, Chestek CA, Patil PG. Estimating Risk for Future Intracranial, Fully Implanted, Modular Neuroprosthetic Systems: A Systematic Review of Hardware Complications in Clinical Deep Brain Stimulation and Experimental Human Intracortical Arrays. Neuromodulation 2019; 23:411-426. [DOI: 10.1111/ner.13069] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 08/05/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Autumn J. Bullard
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | | | - Jiseon Lee
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Electrical Engineering and Computer Science University of Michigan Ann Arbor MI USA
| | - Parag G. Patil
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Neurosurgery University of Michigan Medical School Ann Arbor MI USA
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Pusswald G, Wiesbauer P, Pirker W, Novak K, Foki T, Lehrner J. Depression, quality of life, activities of daily living, and subjective memory after deep brain stimulation in Parkinson disease-A reliable change index analysis. Int J Geriatr Psychiatry 2019; 34:1698-1705. [PMID: 31368144 PMCID: PMC6852657 DOI: 10.1002/gps.5184] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/28/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In the field of Parkinson disease (PD) research, many studies have shown that deep brain stimulation (DBS) can soften side effects, which arise during long-term medical therapy. This study focuses on the changes in depressive symptoms, quality of life (with the subdivisions physical and mental health), activities of daily living, and subjective memory functioning in PD patients testing the baseline and the outcome 1 year after DBS. METHODS For the first time, the reliable change index (RCI) methodology was applied to compare PD-DBS patients (n = 22) with best medically treated PD patients (PD-BMT; n = 28), subjects with mild cognitive impairment (MCI, n = 43) and healthy controls (n = 25) in the above-mentioned domains. The used questionnaires included the revised Beck Depression Inventory (BDI-II), the Short Form (36) Health Survey (SF-36), the Bayer Activities of Daily Living Scale (B-ADL), and the Forgetfulness Assessment Inventory (FAI). RESULTS The reliable change indices show high constant or improved results of the PD-DBS patients in the domains subjective memory (85.7%-100.0%), activities of daily living (60.0%-90.0%), physical health summary (77.8%), depressive symptoms (61.9%), and mental health summary (50.0%) in comparison with the PD-BMT, MCI, and control group. CONCLUSIONS DBS is an established alternative to best medical treatment of PD. The comparisons between the PD-DBS and PD-BMT groups do suggest that the domains mental health, depressive symptoms, and physical health benefit most, while the domains activities of daily living and subjective memory functioning are rather constant. Nevertheless, further research is needed to identify mechanisms and predictors that lead to improvement in individual cases.
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Affiliation(s)
- Gisela Pusswald
- Department of NeurologyMedical University of ViennaViennaAustria
| | | | - Walter Pirker
- Department of NeurologyMedical University of ViennaViennaAustria,Department of NeurologyWilhelminenspitalViennaAustria
| | - Klaus Novak
- Department of NeurosurgeryMedical University of ViennaViennaAustria
| | - Thomas Foki
- Department of NeurologyUniversitätsklinik TullnTullnAustria
| | - Johann Lehrner
- Department of NeurologyMedical University of ViennaViennaAustria
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Liu L, Mariani SG, De Schlichting E, Grand S, Lefranc M, Seigneuret E, Chabardès S. Frameless ROSA® Robot-Assisted Lead Implantation for Deep Brain Stimulation: Technique and Accuracy. Oper Neurosurg (Hagerstown) 2019; 19:57-64. [DOI: 10.1093/ons/opz320] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/31/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Frameless robotic-assisted surgery is an innovative technique for deep brain stimulation (DBS) that has not been assessed in a large cohort of patients.
OBJECTIVE
To evaluate accuracy of DBS lead placement using the ROSA® robot (Zimmer Biomet) and a frameless registration.
METHODS
All patients undergoing DBS surgery in our institution between 2012 and 2016 were prospectively included in an open label single-center study. Accuracy was evaluated by measuring the radial error (RE) of the first stylet implanted on each side and the RE of the final lead position at the target level. RE was measured on intraoperative telemetric X-rays (group 1), on intraoperative O-Arm® (Medtronic) computed tomography (CT) scans (group 2), and on postoperative CT scans or magnetic resonance imaging (MRI) in both groups.
RESULTS
Of 144 consecutive patients, 119 were eligible for final analysis (123 DBS; 186 stylets; 192 leads). In group 1 (76 patients), the mean RE of the stylet was 0.57 ± 0.02 mm, 0.72 ± 0.03 mm for DBS lead measured intraoperatively, and 0.88 ± 0.04 mm for DBS lead measured postoperatively on CT scans. In group 2 (43 patients), the mean RE of the stylet was 0.68 ± 0.05 mm, 0.75 ± 0.04 mm for DBS lead measured intraoperatively; 0.86 ± 0.05 mm and 1.10 ± 0.08 mm for lead measured postoperatively on CT scans and on MRI, respectively No statistical difference regarding the RE of the final lead position was found between the different intraoperative imaging modalities and postoperative CT scans in both groups.
CONCLUSION
Frameless ROSA® robot-assisted technique for DBS reached submillimeter accuracy. Intraoperative CT scans appeared to be reliable and sufficient to evaluate the final lead position.
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Affiliation(s)
- Lannie Liu
- CHU Grenoble Alpes, Clinique Universitaire de Neurochirurgie, Grenoble, France
| | | | | | - Sylvie Grand
- CHU Grenoble Alpes, Department de Neuroradiologie, Grenoble, France
| | - Michel Lefranc
- Department de Neurochirurgie, Amiens-Picardie University Hospital, Amiens, France
| | - Eric Seigneuret
- CHU Grenoble Alpes, Clinique Universitaire de Neurochirurgie, Grenoble, France
| | - Stéphan Chabardès
- CHU Grenoble Alpes, Clinique Universitaire de Neurochirurgie, Grenoble, France
- Inserm, U1216, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
- Clinatec, Centre de Recherche Edmond Safra, CEA-LETI, Grenoble, France
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Sharma VD, Bezchlibnyk YB, Isbaine F, Naik KB, Cheng J, Gale JT, Miocinovic S, Buetefisch C, Factor SA, Willie JT, Boulis NM, Wichmann T, DeLong MR, Gross RE. Clinical outcomes of pallidal deep brain stimulation for dystonia implanted using intraoperative MRI. J Neurosurg 2019; 133:1582-1594. [PMID: 31604331 DOI: 10.3171/2019.6.jns19548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/27/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lead placement for deep brain stimulation (DBS) using intraoperative MRI (iMRI) relies solely on real-time intraoperative neuroimaging to guide electrode placement, without microelectrode recording (MER) or electrical stimulation. There is limited information, however, on outcomes after iMRI-guided DBS for dystonia. The authors evaluated clinical outcomes and targeting accuracy in patients with dystonia who underwent lead placement using an iMRI targeting platform. METHODS Patients with dystonia undergoing iMRI-guided lead placement in the globus pallidus pars internus (GPi) were identified. Patients with a prior ablative or MER-guided procedure were excluded from clinical outcomes analysis. Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores and Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores were assessed preoperatively and at 6 and 12 months postoperatively. Other measures analyzed include lead accuracy, complications/adverse events, and stimulation parameters. RESULTS A total of 60 leads were implanted in 30 patients. Stereotactic lead accuracy in the axial plane was 0.93 ± 0.12 mm from the intended target. Nineteen patients (idiopathic focal, n = 7; idiopathic segmental, n = 5; DYT1, n = 1; tardive, n = 2; other secondary, n = 4) were included in clinical outcomes analysis. The mean improvement in BFMDRS score was 51.9% ± 9.7% at 6 months and 63.4% ± 8.0% at 1 year. TWSTRS scores in patients with predominant cervical dystonia (n = 13) improved by 53.3% ± 10.5% at 6 months and 67.6% ± 9.0% at 1 year. Serious complications occurred in 6 patients (20%), involving 8 of 60 implanted leads (13.3%). The rate of serious complications across all patients undergoing iMRI-guided DBS at the authors' institution was further reviewed, including an additional 53 patients undergoing GPi-DBS for Parkinson disease. In this expanded cohort, serious complications occurred in 11 patients (13.3%) involving 15 leads (10.1%). CONCLUSIONS Intraoperative MRI-guided lead placement in patients with dystonia showed improvement in clinical outcomes comparable to previously reported results using awake MER-guided lead placement. The accuracy of lead placement was high, and the procedure was well tolerated in the majority of patients. However, a number of patients experienced serious adverse events that were attributable to the introduction of a novel technique into a busy neurosurgical practice, and which led to the revision of protocols, product inserts, and on-site training.
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Affiliation(s)
| | - Yarema B Bezchlibnyk
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
- 4Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida; and
| | - Faical Isbaine
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kushal B Naik
- 6Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jennifer Cheng
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
- 5Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | - John T Gale
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Jon T Willie
- Departments of1Neurology and
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nicholas M Boulis
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Robert E Gross
- Departments of1Neurology and
- 3Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Ceylan H, Yasa IC, Kilic U, Hu W, Sitti M. Translational prospects of untethered medical microrobots. ACTA ACUST UNITED AC 2019. [DOI: 10.1088/2516-1091/ab22d5] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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50
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Neuroimaging Technological Advancements for Targeting in Functional Neurosurgery. Curr Neurol Neurosci Rep 2019; 19:42. [DOI: 10.1007/s11910-019-0961-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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