Intraoperative magnetic resonance imaging findings during deep brain stimulation surgery

Clinical article

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Deep brain stimulation (DBS) is an established neurosurgical technique used to treat a variety of neurological disorders, including Parkinson disease, essential tremor, dystonia, epilepsy, depression, and obsessive-compulsive disorder. This study reports on the use of intraoperative MR imaging during DBS surgery to evaluate acute hemorrhage, intracranial air, brain shift, and accuracy of lead placement.


During a 46-month period, 143 patients underwent 152 DBS surgeries including 289 lead placements utilizing intraoperative 1.5-T MR imaging. Imaging was supervised by an MR imaging physicist to maintain the specific absorption rate below the required level of 0.1 W/kg and always included T1 magnetization-prepared rapid gradient echo and T2* gradient echo sequences with selected use of T2 fluid attenuated inversion recovery (FLAIR) and T2 fast spin echo (FSE). Retrospective review of the intraoperative MR imaging examinations was performed to quantify the amount of hemorrhage and the amount of air introduced during the DBS surgery.


Intraoperative MR imaging revealed 5 subdural hematomas, 3 subarachnoid hemorrhages, and 1 intraparenchymal hemorrhage in 9 of the 143 patients. Only 1 patient experiencing a subarachnoid hemorrhage developed clinically apparent symptoms, which included transient severe headache and mild confusion. Brain shift due to intracranial air was identified in 144 separate instances.


Intraoperative MR imaging can be safely performed and may assist in demonstrating acute changes involving intracranial hemorrhage and air during DBS surgery. These findings are rarely clinically significant and typically resolve prior to follow-up imaging. Selective use of T2 FLAIR and T2 FSE imaging can confirm the presence of hemorrhage or air and preclude the need for CT examinations.

Abbreviations used in this paper: DBS = deep brain stimulation; FLAIR = fluid attenuated inversion recovery; FSE = fast spin echo; GRE = gradient echo; MR-RAGE = magnetization-prepared rapid gradient echo; SAR = specific absorption rates; VIM = ventral intermediate nucleus.

Article Information

Address correspondence to: Robert Watson, M.D., Ph.D., Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905. email:

Please include this information when citing this paper: published online June 24, 2011; DOI: 10.3171/2011.5.JNS101457.

© AANS, except where prohibited by US copyright law.



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    Subdural hematoma. This 69-year-old woman with Parkinson disease underwent bilateral subthalamic nucleus DBS placement. Intraoperative MR imaging revealed a right 8-mm subdural hematoma characterized as isointense (arrows) on both T2* GRE (A) and T1 MP-RAGE (B) sequences. The lesion displayed high signal intensity (arrow) on FLAIR imaging (C). Computed tomography confirmed the presence of a subdural hematoma (arrow, D).

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    Subarachnoid hemorrhage. This 62-year-old woman with Parkinson disease who underwent bilateral subthalamic nucleus DBS electrode placement was found to have a small focus of subarachnoid hemorrhage. The preoperative MR images demonstrated low signal intensity CSF within the left frontal sulcus (arrow, A). The hemorrhage was mildly hyperintense relative to CSF with T1 MP-RAGE (arrow, B), and isointense to CSF on T2* GRE (arrow, C); it demonstrated pronounced FLAIR hyperintensity (arrow, D). The presence of the subarachnoid hemorrhage was confirmed with CT (arrow, E).

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    Intraparenchymal hemorrhage. This 70-year-old male with Parkinson disease underwent bilateral subthalamic nucleus DBS electrode placement. The intraoperative MR images showed a 5 × 5 mm hematoma within the right basal ganglia. Intraoperative T1 MP-RAGE demonstrated the DBS lead but the adjacent hemorrhage (arrow, B) was isointense and nearly undetectable when compared with the preoperative image (A). On T2* GRE the hematoma was characterized as isointense with a peripheral margin of low signal intensity (arrow, C) and high signal intensity on axial T2 FSE sequences (arrow, D). Computed tomography confirmed the presence of the hematoma (arrow, E). In addition the CT scan shows bilateral brain settling or shift that is also present but not as evident on the intraoperative MR images.

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    Pneumocephalus. This 58-year-old woman underwent bilateral VIM DBS for treatment of an essential tremor. The procedure included replacement of a previously placed left VIM lead. Preoperative MR imaging showed postoperative changes including a prominent left frontal sulcus (arrow, A) with low signal intensity CSF. Intraoperative T1 MP-RAGE showed low signal intensity within this sulcus due to air, similar to the preoperative study (arrow, B). T2* GRE represented the air as an absence of signal with blooming due to susceptibility effects (arrow, C). The CT scan confirmed the presence of subarachnoid air (arrow, D).



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