Frameless deep brain stimulation using intraoperative O-arm technology

Clinical article

Restricted access

Object

Correct lead location in the desired target has been proven to be a strong influential factor for good clinical outcome in deep brain stimulation (DBS) surgery. Commonly, a surgeon's first reliable assessment of such location is made on postoperative imaging. While intraoperative CT (iCT) and intraoperative MR imaging have been previously described, the authors present a series of frameless DBS procedures using O-arm iCT.

Methods

Twelve consecutive patients with 15 leads underwent frameless DBS placement using electrophysiological testing and O-arm iCT. Initial target coordinates were made using standard indirect and direct assessment. Microelectrode recording (MER) with kinesthetic responses was performed, followed by microstimulation to evaluate the side-effect profile. Intraoperative 3D CT acquisitions obtained between each MER pass and after final lead placement were fused with the preoperative MR image to verify intended MER movements around the target area and to identify the final lead location. Tip coordinates from the initial plan, final intended target, and actual lead location on iCT were later compared with the lead location on postoperative MR imaging, and euclidean distances were calculated. The amount of radiation exposure during each procedure was calculated and compared with the estimated radiation exposure if iCT was not performed.

Results

The mean euclidean distances between the coordinates for the initial plan, final intended target, and actual lead on iCT compared with the lead coordinates on postoperative MR imaging were 3.04 ± 1.45 mm (p = 0.0001), 2.62 ± 1.50 mm (p = 0.0001), and 1.52 ± 1.78 mm (p = 0.0052), respectively. The authors obtained good merging error during image fusion, and postoperative brain shift was minimal. The actual radiation exposure from iCT was invariably less than estimates of exposure using standard lateral fluoroscopy and anteroposterior radiographs (p < 0.0001).

Conclusions

O-arm iCT may be useful in frameless DBS surgery to approximate microelectrode or lead locations intraoperatively. Intraoperative CT, however, may not replace fundamental DBS surgical techniques such as electrophysiological testing in movement disorder surgery. Despite the lack of evidence for brain shift from the procedure, iCT-measured coordinates were statistically different from those obtained postoperatively, probably indicating image merging inaccuracy and the difficulties in accurately denoting lead location. Therefore, electrophysiological testing may truly be the only means of precisely knowing the location in 3D space intraoperatively. While iCT may provide clues to electrode or lead location during the procedure, its true utility may be in DBS procedures targeting areas where electrophysiology is less useful. The use of iCT appears to reduce radiation exposure compared with the authors' traditional frameless technique.

Abbreviations used in this paper: ALARA = as low as reasonably achievable; AP = anteroposterior; cZI = caudal zona incerta; DBS = deep brain stimulation; GPi = internal globus pallidus; iCT = intraoperative CT; iMR = intraoperative MR; MER = microelectrode recording; MS = multiple sclerosis; PD = Parkinson disease; STN = subthalamic nucleus; Vim = ventralis intermedius nucleus.

Article Information

Address correspondence to: Adam P. Smith, M.D., Department of Neurosurgery, Rush University Medical Center, 1725 West Harrison Avenue, Suite 1115, Chicago, Illinois 60612. email: Adam_Smith@rush.edu.

Please include this information when citing this paper: published online April 15, 2011; DOI: 10.3171/2011.3.JNS101642.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Operating room setup demonstrating position of O-arm and planning station in relation to the patient. Electrophysiology equipment is out of the picture on the opposite side of the patient caudal to the operative field.

  • View in gallery

    Preoperative StealthStation views showing the intended target based on indirect and direct planning. These coordinates are later compared with the coordinates of the actual lead on postoperative MR imaging, and the euclidean distance is calculated.

  • View in gallery

    StealthStation views showing the final location of planned target after electrophysiological testing. The yellow trajectory is the initial intended target based on preoperative planning, but microelectrode recording and microstimulation suggested that the final target should be anterior and medial as shown by the purple trajectory. These final planned coordinates are later compared with the coordinates of the actual lead on postoperative MR imaging, and the euclidean distance is calculated. Of note, these final planned coordinates are not necessarily the actual coordinates of the moved microelectrode. These coordinates are calculated by the distance moved from the preoperative intended target based on set distances on the microdrive.

  • View in gallery

    StealthStation views showing final lead coordinates on the merged iCT. These iCT coordinates are later compared with the coordinates of the actual lead on postoperative MR imaging, and the euclidean distance is calculated. The yellow trajectory is the initial intended target based on preoperative planning, the purple trajectory is the final planned target after electrophysiological testing, and the red trajectory marks the lead itself on iCT. Of note, the red trajectory is extrapolated by centering its tip in the iCT artifact (tip of the actual lead).

  • View in gallery

    Intraoperative AP radiographs of frame-based procedures. Left: Lead in the GPi. Right: Bilateral leads in the STN. Note the more lateral entry point on the skull for the GPi lead, making the frameless techniques less desirable than for the STN target.

  • View in gallery

    Postoperative CT scan (left) and MR image (right) obtained after a bilateral procedure, showing no pneumocephalus or brain shift. This was a consistent finding in our series.

  • View in gallery

    StealthStation view used to confirm the merge of the preoperative MR imaging (right half) and preoperative CT (left half). We achieved extremely low merging error in our series.

References

  • 1

    Anheim MBatir AFraix VSilem MChabardès SSeigneuret E: Improvement in Parkinson disease by subthalamic nucleus stimulation based on electrode placement: effects of reimplantation. Arch Neurol 65:6126162008

  • 2

    Bakay RA: Metaanalysis, pallidotomy, and microelectrodes. J Neurosurg 97:125312562002

  • 3

    Bejjani BPDormont DPidoux BYelnik JDamier PArnulf I: Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg 92:6156252000

  • 4

    Bjartmarz HRehncrona S: Comparison of accuracy and precision between frame-based and frameless stereotactic navigation for deep brain stimulation electrode implantation. Stereotact Funct Neurosurg 85:2352422007

  • 5

    Brenner DJHall EJ: Computed tomography—an increasing source of radiation exposure. N Engl J Med 357:227722842007

  • 6

    Caire FGantois CTorny FRanoux DMaubon AMoreau JJ: Intraoperative use of the Medtronic O-arm for deep brain stimulation procedures. Stereotact Funct Neurosurg 88:1091142010

  • 7

    Cardis EVrijheid MBlettner MGilbert EHakama MHill C: The 15-country collaborative study of cancer risk among radiation workers in the nuclear industry: estimates of radiation-related cancer risks. Radiat Res 167:3964162007

  • 8

    Coubes PVayssiere NEl Fertit HHemm SCif LKienlen J: Deep brain stimulation for dystonia. Surgical technique. Stereotact Funct Neurosurg 78:1831912002

  • 9

    Elias WJFu KMFrysinger RC: Cortical and subcortical brain shift during stereotactic procedures. J Neurosurg 107:9839882007

  • 10

    Ellis TMFoote KDFernandez HHSudhyadhom ARodriguez RLZeilman P: Reoperation for suboptimal outcomes after deep brain stimulation surgery. Neurosurgery 63:7547612008

  • 11

    Euler EHeining SRiquarts CMutschler W: C-arm-based three-dimensional navigation: a preliminary feasibility study. Comput Aided Surg 8:35412003

  • 12

    Fiegele TFeuchtner GSohm FBauer RAnton JVGotwald T: Accuracy of stereotactic electrode placement in deep brain stimulation by intraoperative computed tomography. Parkinsonism Relat Disord 14:5955992008

  • 13

    Gross REKrack PRodriguez-Oroz MCRezai ARBenabid AL: Electrophysiological mapping for the implantation of deep brain stimulators for Parkinson's disease and tremor. Mov Disord 21:Suppl 14S259S2832006

  • 14

    Halpern CHDanish SFBaltuch GHJaggi JL: Brain shift during deep brain stimulation surgery for Parkinson's disease. Stereotact Funct Neurosurg 86:37432008

  • 15

    Hamani CMayberg HSnyder BGiacobbe PKennedy SLozano AM: Deep brain stimulation of the subcallosal cingulate gyrus for depression: anatomical location of active contacts in clinical responders and a suggested guideline for targeting. Clinical article. J Neurosurg 111:120912152009

  • 16

    Hamid NAMitchell RDMocroft PWestby GWMMilner JPall H: Targeting the subthalamic nucleus for deep brain stimulation: technical approach and fusion of pre- and postoperative MR images to define accuracy of lead placement. J Neurol Neurosurg Psychiatry 76:4094142005

  • 17

    Holly LTFoley KT: Three-dimensional fluoroscopy-guided percutaneous thoracolumbar pedicle screw placement. Technical note. J Neurosurg 99:3 Suppl3243292003

  • 18

    Ito YSugimoto YTomioka MHasegawa YNakago KYagata Y: Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion. Clinical article. J Neurosurg Spine 9:4504532008

  • 19

    Khan MFMewes KGross RESkrinjar O: Assessment of brain shift related to deep brain stimulation surgery. Stereotact Funct Neurosurg 86:44532008

  • 20

    Malone DA JrDougherty DDRezai ARCarpenter LLFriehs GMEskandar EN: Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry 65:2672752009

  • 21

    Martin AJLarson PSOstrem JLSootsman WKTalke PWeber OM: Placement of deep brain stimulator electrodes using real-time high-field interventional magnetic resonance imaging. Magn Reson Med 54:110711142005

  • 22

    McClelland S IIIFord BSenatus PBWinfield LMDu YEPullman SL: Subthalamic stimulation for Parkinson disease: determination of electrode location necessary for clinical efficacy. Neurosurg Focus 19:5E122005

  • 23

    Miller KJMakeig SHebb AORao RPdenNijs MOjemann JG: Cortical electrode localization from X-rays and simple mapping for electrocorticographic research: The “Location on Cortex” (LOC) package for MATLAB. J Neurosci Methods 162:3033082007

  • 24

    Miyagi YShima FSasaki T: Brain shift: an error factor during implantation of deep brain stimulation electrodes. J Neurosurg 107:9899972007

  • 25

    Pallavaram SDawant BMRemple MSNeimat JSKao CKonrad PE: Effect of brain shift on the creation of functional atlases for deep brain stimulation surgery. Int J CARS 5:2212282010

  • 26

    Pierce DAPreston DL: Radiation-related cancer risks at low doses among atomic bomb survivors. Radiat Res 154:1781862000

  • 27

    Plaha PKhan SGill SS: Bilateral stimulation of the caudal zona incerta nucleus for tremor control. J Neurol Neurosurg Psychiatry 79:5045132008

  • 28

    Plaha PPatel NKGill SS: Stimulation of the subthalamic region for essential tremor. J Neurosurg 101:48542004

  • 29

    Preston DLRon ETokuoka SFunamoto SNishi NSoda M: Solid cancer incidence in atomic bomb survivors: 1958–1998. Radiat Res 168:1642007

  • 30

    Rajasekaran SVidyadhara SShetty AP: Intra-operative Iso-C3D navigation for pedicle screw instrumentation of hangman's fracture: a case report. J Orthop Surg (Hong Kong) 15:73772007

  • 31

    Richardson RMOstrem JLStarr PA: Surgical repositioning of misplaced subthalamic electrodes in Parkinson's disease: location of effective and ineffective leads. Stereotact Funct Neurosurg 87:2973032009

  • 32

    Schrader BHamel WWeinert DMehdorn HM: Documentation of electrode localization. Mov Disord 17:Suppl 3S167S1742002

  • 33

    Shahlaie KLarson PSStarr PA: Intra-operative CT for DBS surgery: technique and accuracy assessment. Neurosurgery [epub ahead of print]2010

  • 34

    Starr PAMartin AJOstrem JLTalke PLevesque NLarson PS: Subthalamic nucleus deep brain stimulator placement using high-field interventional magnetic resonance imaging and a skull-mounted aiming device: technique and application accuracy. Clinical article. J Neurosurg 112:4794902010

  • 35

    van den Munckhof PContarino MFBour LJSpeelman JDde Bie RMSchuurman PR: Postoperative curving and upward displacement of deep brain stimulation electrodes caused by brain shift. Neurosurgery 67:49542010

  • 36

    Villavicencio ATBurneikiene SBulsara KRThramann JJ: Intraoperative three-dimensional fluoroscopy-based computerized tomography guidance for percutaneous kyphoplasty. Neurosurg Focus 18:3e32005

  • 37

    Wang MYKim KALiu CYKim PApuzzo ML: Reliability of three-dimensional fluoroscopy for detecting pedicle screw violations in the thoracic and lumbar spine. Neurosurgery 54:113811432004

  • 38

    Zrinzo Lvan Hulzen ALGorgulho AALimousin PStaal MJDe Salles AA: Avoiding the ventricle: a simple step to improve accuracy of anatomical targeting during deep brain stimulation. Clinical article. J Neurosurg 110:128312902009

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 162 162 21
Full Text Views 184 184 3
PDF Downloads 120 120 4
EPUB Downloads 0 0 0

PubMed

Google Scholar