Magnetic resonance imaging techniques for visualization of the subthalamic nucleus

A review

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The authors reviewed 70 publications on MR imaging–based targeting techniques for identifying the subthalamic nucleus (STN) for deep brain stimulation in patients with Parkinson disease. Of these 70 publications, 33 presented quantitatively validated results.

There is still no consensus on which targeting technique to use for surgery planning; methods vary greatly between centers. Some groups apply indirect methods involving anatomical landmarks, or atlases incorporating anatomical or functional data. Others perform direct visualization on MR imaging, using T2-weighted spin echo or inversion recovery protocols.

The combined studies do not offer a straightforward conclusion on the best targeting protocol. Indirect methods are not patient specific, leading to varying results between cases. On the other hand, direct targeting on MR imaging suffers from lack of contrast within the subthalamic region, resulting in a poor delineation of the STN. These deficiencies result in a need for intraoperative adaptation of the original target based on test stimulation with or without microelectrode recording.

It is expected that future advances in MR imaging technology will lead to improvements in direct targeting. The use of new MR imaging modalities such as diffusion MR imaging might even lead to the specific identification of the different functional parts of the STN, such as the dorsolateral sensorimotor part, the target for deep brain stimulation.

Abbreviations used in this paper: AC = anterior commissure; DBS = deep brain stimulation; FSE = fast spin echo; IR = inversion recovery; MCP = midcommissural point; MER = microelectrode recording; MPRAGE = magnetization prepared rapid acquisition gradient echo; PC = posterior commissure; STIR = short tau inversion recovery; STN = subthalamic nucleus; TSE = turbo spin echo.

Article Information

Address correspondence to: Ellen J. L. Brunenberg, Eindhoven University of Technology, Department of Biomedical Engineering, WH 2.106, PO Box 513, 5600 MB Eindhoven, The Netherlands. email:

Please include this information when citing this paper: published online July 29, 2011; DOI: 10.3171/2011.6.JNS101571.

© AANS, except where prohibited by US copyright law.



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    Diagram showing AC-PC line–based targeting in a sagittal plane. After the AC and PC are identified, the midcommissural point (MCP) is determined. From there, the STN position can be calculated using fixed distances (often 12 mm lateral, 3 mm inferior, and 3 mm posterior) based on an atlas.

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    Diagram showing red nucleus–based targeting in an axial plane. The center of the STN lies on the same line as the anterior boundary of the red nucleus (RN).

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    Diagram showing targeting based on the nigrocapsular angle, in a sagittal plane. The STN lies in the corner that is formed by the descending internal capsule (IC) and the substantia nigra (SN).

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    Diagram illustrating the concept of indirect targeting based on atlas mapping. On the upper left, an atlas slice with anatomical information can be seen, containing labeled structures. At the bottom left, a functional atlas is represented, consisting of a cloud of target points that were used in previously performed DBS operations. On the right, the patient's MR imaging data can be seen. The gray arrows represent the transformation that is necessary to map the atlases to the patient's MR imaging data, resulting in overlaid information as shown in the center.

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    Coronal T2-weighted FSE MR image showing direct visualization of the STN.

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    Coronal IR MR image showing direct visualization of the STN.

  • View in gallery

    Axial susceptibility-weighted MR image showing direct visualization of the STN.



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