1
|
Fayed I, Smit RD, Vinjamuri S, Kang K, Sathe A, Sharan A, Wu C. Robot-Assisted Minimally Invasive Asleep Single-Stage Deep Brain Stimulation Surgery: Operative Technique and Systematic Review. Oper Neurosurg (Hagerstown) 2024; 26:363-371. [PMID: 37888994 DOI: 10.1227/ons.0000000000000977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/16/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Robotic assistance has garnered increased use in neurosurgery. Recently, this has expanded to include deep brain stimulation (DBS). Several studies have reported increased accuracy and improved efficiency with robotic assistance, but these are limited to individual robotic platforms with smaller sample sizes or are broader studies on robotics not specific to DBS. Our objectives are to report our technique for robot-assisted, minimally invasive, asleep, single-stage DBS surgery and to perform a meta-analysis comparing techniques from previous studies. METHODS We performed a single-center retrospective review of DBS procedures using a floor-mounted robot with a frameless transient fiducial array registration. We compiled accuracy data (radial entry error, radial target error, and 3-dimensional target error) and efficiency data (operative time, setup time, and total procedure time). We then performed a meta-analysis of previous studies and compared these metrics. RESULTS We analyzed 315 electrodes implanted in 160 patients. The mean radial target error was 0.9 ± 0.5 mm, mean target 3-dimensional error was 1.3 ± 0.7 mm, and mean radial entry error was 1.1 ± 0.8 mm. The mean procedure time (including pulse generator placement) was 182.4 ± 47.8 minutes, and the mean setup time was 132.9 ± 32.0 minutes. The overall complication rate was 8.8% (2.5% hemorrhagic/ischemic, 2.5% infectious, and 0.6% revision). Our meta-analysis showed increased accuracy with floor-mounted over skull-mounted robotic platforms and with fiducial-based registrations over optical registrations. CONCLUSION Our technique for robot-assisted, minimally invasive, asleep, single-stage DBS surgery is safe, accurate, and efficient. Our data, combined with a meta-analysis of previous studies, demonstrate that robotic assistance can provide similar or increased accuracy and improved efficiency compared with traditional frame-based techniques. Our analysis also suggests that floor-mounted robots and fiducial-based registration methods may be more accurate.
Collapse
Affiliation(s)
- Islam Fayed
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Rupert D Smit
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Shreya Vinjamuri
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - KiChang Kang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Anish Sathe
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Ashwini Sharan
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Chengyuan Wu
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| |
Collapse
|
2
|
Vedaei F, Fayed I, Alizadeh M, Miller C, Zhang AB, Koa V, Khan S, Mohamed FB, Wu C. Effect of Enlarged Perivascular Spaces in Reliable Distinction of Prospective Targeting During Deep Brain Stimulation in Patients With Advanced Parkinson's Disease: A Study of Deterministic and Probabilistic Tractography. Neurosurgery 2023; 93:691-698. [PMID: 37010304 DOI: 10.1227/neu.0000000000002478] [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: 11/07/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Precise electrode position is vital for effective deep brain stimulation in treating motor symptoms in Parkinson's disease (PD). Enlarged perivascular spaces (PVSs) are associated with pathophysiology of neurodegenerative diseases including PD and may affect the microstructure of surrounding brain tissue. OBJECTIVE To quantify the clinical implications of enlarged PVS on tractography-based stereotactic targeting in patients with advanced PD selected to undergo deep brain stimulation. METHODS Twenty patients with PD underwent MRI scanning. The PVS areas were visualized and segmented. Based on the size of the PVS areas, the patient group was split into 2 categories of large vs small PVSs. Probabilistic and deterministic tractography methods were applied to a diffusion-weighted data set. Fiber assignment was performed using motor cortex as an initiation seed and the globus pallidus interna and subthalamic nucleus, separately, as inclusion masks. Two exclusion masks used consisted of cerebral peduncles and the PVS mask. The center of gravity of the tract density map was measured and compared between the tracts generated with and without consideration of the PVS mask. RESULTS The average differences between the center of gravity of the tracts made by excluding PVS and without excluding PVS using deterministic and probabilistic tractography methods were less than 1 mm. Statistical analysis showed nonsignificant differences between deterministic and probabilistic methods and differences between patients with large and small PVSs ( P > .05). CONCLUSION This study demonstrated that the presence of enlarged PVS is unlikely to affect targeting of basal ganglia nuclei based on tractography.
Collapse
Affiliation(s)
- Faezeh Vedaei
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Islam Fayed
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Mahdi Alizadeh
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Christopher Miller
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Ashley B Zhang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Victoria Koa
- College of Medicine, Drexel University, Philadelphia , Pennsylvania , USA
| | - Suharto Khan
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Feroze B Mohamed
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Chengyuan Wu
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| |
Collapse
|
3
|
Holcomb JM, Chopra R, Feltrin FS, Elkurd M, El-Nazer R, McKenzie L, O’Suilleabhain P, Maldjian JA, Dauer W, Shah BR. Improving tremor response to focused ultrasound thalamotomy. Brain Commun 2023; 5:fcad165. [PMID: 37533544 PMCID: PMC10390385 DOI: 10.1093/braincomms/fcad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 08/04/2023] Open
Abstract
MRI-guided high-intensity focused ultrasound thalamotomy is an incisionless therapy for essential tremor. To reduce adverse effects, the field has migrated to treating at 2 mm above the anterior commissure-posterior commissure plane. We perform MRI-guided high-intensity focused ultrasound with an advanced imaging targeting technique, four-tract tractography. Four-tract tractography uses diffusion tensor imaging to identify the critical white matter targets for tremor control, the decussating and non-decussating dentatorubrothalamic tracts, while the corticospinal tract and medial lemniscus are identified to be avoided. In some patients, four-tract tractography identified a risk of damaging the medial lemniscus or corticospinal tract if treated at 2 mm superior to the anterior commissure-posterior commissure plane. In these patients, we chose to target 1.2-1.5 mm superior to the anterior commissure-posterior commissure plane. In these patients, post-operative imaging revealed that the focused ultrasound lesion extended into the posterior subthalamic area. This study sought to determine if patients with focused ultrasound lesions that extend into the posterior subthalamic area have a differnce in tremor improvement than those without. Twenty essential tremor patients underwent MRI-guided high-intensity focused ultrasound and were retrospectively classified into two groups. Group 1 included patients with an extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. Group 2 included patients without extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. For each patient, the percent change in postural tremor, kinetic tremor and Archimedes spiral scores were calculated between baseline and a 3-month follow-up. Two-tailed Wilcoxon rank-sum tests were used to compare the improvement in tremor scores, the total number of sonications, thermal dose to achieve initial tremor response, and skull density ratio between groups. Group 1 had significantly greater postural, kinetic, and Archimedes spiral score percent improvement than Group 2 (P values: 5.41 × 10-5, 4.87 × 10-4, and 5.41 × 10-5, respectively). Group 1 also required significantly fewer total sonications to control the tremor and a significantly lower thermal dose to achieve tremor response (P values: 6.60 × 10-4 and 1.08 × 10-5, respectively). No significant group differences in skull density ratio were observed (P = 1.0). We do not advocate directly targeting the posterior subthalamic area with MRI-guided high-intensity focused ultrasound because the shape of the focused ultrasound lesion can result in a high risk of adverse effects. However, when focused ultrasound lesions naturally extend from the thalamus into the posterior subthalamic area, they provide greater tremor control than those that only involve the thalamus.
Collapse
Affiliation(s)
- James M Holcomb
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rajiv Chopra
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Fabricio S Feltrin
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Mazen Elkurd
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rasheda El-Nazer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Lauren McKenzie
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | | | - Joseph A Maldjian
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - William Dauer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
- O’Donnell Brain Institute, UTSW Medical Center, Dallas, TX 75235, USA
| | - Bhavya R Shah
- Correspondence to: Bhavya R. Shah Department of Radiology, UTSW Medical Center, 1801 Inwood Rd Dallas, TX 75235, USA E-mail:
| |
Collapse
|
4
|
Pfefferbaum A, Sullivan EV, Zahr NM, Pohl KM, Saranathan M. Multi-atlas thalamic nuclei segmentation on standard T1-weighed MRI with application to normal aging. Hum Brain Mapp 2022; 44:612-628. [PMID: 36181510 PMCID: PMC9842912 DOI: 10.1002/hbm.26088] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/15/2022] [Accepted: 09/01/2022] [Indexed: 01/25/2023] Open
Abstract
Specific thalamic nuclei are implicated in healthy aging and age-related neurodegenerative diseases. However, few methods are available for robust automated segmentation of thalamic nuclei. The threefold aims of this study were to validate the use of a modified thalamic nuclei segmentation method on standard T1 MRI data, to apply this method to quantify age-related volume declines, and to test functional meaningfulness by predicting performance on motor testing. A modified version of THalamus Optimized Multi-Atlas Segmentation (THOMAS) generated 22 unilateral thalamic nuclei. For validation, we compared nuclear volumes obtained from THOMAS parcellation of white-matter-nulled (WMn) MRI data to T1 MRI data in 45 participants. To examine the effects of age/sex on thalamic nuclear volumes, T1 MRI available from a second data set of 121 men and 117 women, ages 20-86 years, were segmented using THOMAS. To test for functional ramifications, composite regions and constituent nuclei were correlated with Grooved Pegboard test scores. THOMAS on standard T1 data showed significant quantitative agreement with THOMAS from WMn data, especially for larger nuclei. Sex differences revealing larger volumes in men than women were accounted for by adjustment with supratentorial intracranial volume (sICV). Significant sICV-adjusted correlations between age and thalamic nuclear volumes were detected in 20 of the 22 unilateral nuclei and whole thalamus. Composite Posterior and Ventral regions and Ventral Anterior/Pulvinar nuclei correlated selectively with higher scores from the eye-hand coordination task. These results support the use of THOMAS for standard T1-weighted data as adequately robust for thalamic nuclear parcellation.
Collapse
Affiliation(s)
- Adolf Pfefferbaum
- Center for Health SciencesSRI InternationalMenlo ParkCaliforniaUSA,Department of Psychiatry & Behavioral SciencesStanford University School of MedicineStanfordCaliforniaUSA
| | - Edith V. Sullivan
- Department of Psychiatry & Behavioral SciencesStanford University School of MedicineStanfordCaliforniaUSA
| | - Natalie M. Zahr
- Center for Health SciencesSRI InternationalMenlo ParkCaliforniaUSA,Department of Psychiatry & Behavioral SciencesStanford University School of MedicineStanfordCaliforniaUSA
| | - Kilian M. Pohl
- Center for Health SciencesSRI InternationalMenlo ParkCaliforniaUSA,Department of Psychiatry & Behavioral SciencesStanford University School of MedicineStanfordCaliforniaUSA
| | - Manojkumar Saranathan
- Department of RadiologyUniversity of Massachusetts Chan Medical SchoolWorcesterMassachusettsUSA
| |
Collapse
|
5
|
Baumgartner AJ, Thompson JA, Kern DS, Ojemann SG. Novel targets in deep brain stimulation for movement disorders. Neurosurg Rev 2022; 45:2593-2613. [PMID: 35511309 DOI: 10.1007/s10143-022-01770-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/01/2021] [Accepted: 03/08/2022] [Indexed: 12/26/2022]
Abstract
The neurosurgical treatment of movement disorders, primarily via deep brain stimulation (DBS), is a rapidly expanding and evolving field. Although conventional targets including the subthalamic nucleus (STN) and internal segment of the globus pallidus (GPi) for Parkinson's disease and ventral intermediate nucleus of the thalams (VIM) for tremor provide substantial benefit in terms of both motor symptoms and quality of life, other targets for DBS have been explored in an effort to maximize clinical benefit and also avoid undesired adverse effects associated with stimulation. These novel targets primarily include the rostral zona incerta (rZI), caudal zona incerta (cZI)/posterior subthalamic area (PSA), prelemniscal radiation (Raprl), pedunculopontine nucleus (PPN), substantia nigra pars reticulata (SNr), centromedian/parafascicular (CM/PF) nucleus of the thalamus, nucleus basalis of Meynert (NBM), dentato-rubro-thalamic tract (DRTT), dentate nucleus of the cerebellum, external segment of the globus pallidus (GPe), and ventral oralis (VO) complex of the thalamus. However, reports of outcomes utilizing these targets are scattered and disparate. In order to provide a comprehensive resource for researchers and clinicians alike, we have summarized the existing literature surrounding these novel targets, including rationale for their use, neurosurgical techniques where relevant, outcomes and adverse effects of stimulation, and future directions for research.
Collapse
Affiliation(s)
| | - John A Thompson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Hospital, 12631 East 17th Avenue, PO Box 6511, Aurora, CO, 80045, USA
| | - Drew S Kern
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Hospital, 12631 East 17th Avenue, PO Box 6511, Aurora, CO, 80045, USA
| | - Steven G Ojemann
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
- University of Colorado Hospital, 12631 East 17th Avenue, PO Box 6511, Aurora, CO, 80045, USA.
| |
Collapse
|