Accuracy of deep brain stimulation electrode placement using intraoperative computed tomography without microelectrode recording

Clinical article

Restricted access


In this prospective study the authors' objective was to evaluate the accuracy of deep brain stimulation (DBS) electrode placement using image guidance for direct anatomical targeting with intraoperative CT.


Preoperative 3-T MR images were merged with intraoperative CT images for planning. Electrode targets were anatomical, based on the MR images. A skull-mounted NexFrame system was used for electrode placement, and all procedures were performed under general anesthesia. After electrode placement, intraoperative CT images were merged with trajectory planning images to calculate accuracy. Accuracy was assessed by both vector error and deviation off the planned trajectory.


Sixty patients (33 with Parkinson disease, 26 with essential tremor, and 1 with dystonia) underwent the procedure. Patient's mean age was 64 ± 9.5 years. Over an 18-month period, 119 electrodes were placed (all bilateral, except one). Electrode implant locations were the ventral intermediate nucleus (VIM), globus pallidus internus (GPI), and subthalamic nucleus (STN) in 25, 23, and 12 patients, respectively. Target accuracy measurements were as follows: mean vector error 1.59 ± 1.11 mm and mean deviation off trajectory 1.24 ± 0.87 mm. There was no statistically significant difference between the accuracy of left and right brain electrodes. There was a statistically significant (negative) correlation between the distance of the closest approach of the electrode trajectory to the ventricular wall of the lateral ventricle and vector error (r2 = −0.339, p < 0.05, n = 76), and the deviation from the planned trajectory (r2 = −0.325, p < 0.05, n = 77). Furthermore, when the distance from the electrode trajectory and the ventricular wall was < 4 mm, the correlation of the ventricular distance to the deviation from the planned trajectory was stronger (r2 = −0.419, p = 0.05, n = 19). Electrodes placed in the GPI were significantly more accurate than those placed in the VIM (p < 0.05). Only 1 of 119 electrodes required intraoperative replacement due to a vector error > 3 mm. In this series there was one infection and no intraparenchymal hemorrhages.


Placement of DBS electrodes using an intraoperative CT scanner and the NexFrame achieves an accuracy that is at least comparable to other methods.

Abbreviations used in this paper:DBS = deep brain stimulation; GPI = globus pallidus internus; MER = microelectrode recording; STN = subthalamic nucleus; VIM = ventral intermediate nucleus.

Article Information

Address correspondence to: Ahmed M. Raslan, M.D., Department of Neurological Surgery, Oregon Health & Science University, Mail code CH8N, 3303 SW Bond Avenue, Portland, Oregon 97239-3098. email:

Please include this information when citing this paper: published online May 31, 2013; DOI: 10.3171/2013.4.JNS122324.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Calculation of the trajectory (T) and vector (V) errors. Inset demonstrates the MR image merged with the final intraoperative CT scan. The target electrode could be directly visualized, and its Cartesian coordinates (x, y, and z) determined. These coordinates were used to derive the trajectory and vector errors by direct comparison with the coordinates of the planned target. Printed with permission from Andy Rekito, M.S., Oregon Health & Science University.

  • View in gallery

    A: Distance from the ventricle and trajectory deviation error (r2 = −0.325, p < 0.05, n = 77). B: Distance from the ventricle and vector error (r2 = −0.339, p < 0.05, n = 76). C: Distance from the ventricle wall < 4 mm and trajectory deviation error (r2 = −0.419, p = 0.05, n = 19).



Benabid ALPollak PGervason CHoffmann DGao DMHommel M: Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet 337:4034061991


Burchiel KJThe future of microelectrode recording. Israel ZBurchiel K: Microelectrode Recording in Movement Disorder Surgery New YorkThieme2004. 208210


Burchiel KJAnderson VCFavre JHammerstad JP: Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinson's disease: results of a randomized, blinded pilot study. Neurosurgery 45:137513841999


Deuschl GSchade-Brittinger CKrack PVolkmann JSchäfer HBötzel K: A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med 355:8969082006


Hariz MI: Safety and risk of microelectrode recording in surgery for movement disorders. Stereotact Funct Neurosurg 78:1461572002


Henderson JMHolloway KLGaede SERosenow JM: The application accuracy of a skull-mounted trajectory guide system for image-guided functional neurosurgery. Comput Aided Surg 9:1551602004


Kupsch ABenecke RMüller JTrottenberg TSchneider GHPoewe W: Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med 355:197819902006


Schaltenbrand GWahren W: Atlas for Stereotaxy of the Human Brain ed 2StuttgartThieme1977


Servello DPorta MSassi MBrambilla ARobertson MM: Deep brain stimulation in 18 patients with severe Gilles de la Tourette syndrome refractory to treatment: the surgery and stimulation. J Neurol Neurosurg Psychiatry 79:1361422008


Shahlaie KLarson PSStarr PA: Intraoperative computed tomography for deep brain stimulation surgery: technique and accuracy assessment. Neurosurgery 68:1 Suppl Operative1141242011


Starr PAChristine CWTheodosopoulos PVLindsey NByrd DMosley A: Implantation of deep brain stimulators into the subthalamic nucleus: technical approach and magnetic resonance imaging-verified lead locations. J Neurosurg 97:3703872002


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


Sudhyadhom AHaq IUFoote KDOkun MSBova FJ: A high resolution and high contrast MRI for differentiation of subcortical structures for DBS targeting: the Fast Gray Matter Acquisition T1 Inversion Recovery (FGATIR). Neuroimage 47:Suppl 2T44T522009


Theodosopoulos PVMarks WJ JrChristine CStarr PA: Locations of movement-related cells in the human subthalamic nucleus in Parkinson's disease. Mov Disord 18:7917982003


Vidailhet MVercueil LHoueto JLKrystkowiak PBenabid ALCornu P: Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med 352:4594672005


Weaver FMFollett KStern MHur KHarris CMarks WJ Jr: Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA 301:63732009


Zrinzo LFoltynie TLimousin PHariz MI: Reducing hemorrhagic complications in functional neurosurgery: a large case series and systematic literature review. Clinical article. J Neurosurg 116:84942012


Cited By



All Time Past Year Past 30 Days
Abstract Views 261 261 84
Full Text Views 407 407 33
PDF Downloads 203 203 18
EPUB Downloads 0 0 0


Google Scholar