Three-dimensional SPACE fluid-attenuated inversion recovery at 3 T to improve subthalamic nucleus lead placement for deep brain stimulation in Parkinson's disease: from preclinical to clinical studies

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OBJECTIVE

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established therapy for motor symptoms in patients with pharmacoresistant Parkinson's disease (PD). However, the procedure, which requires multimodal perioperative exploration such as imaging, electrophysiology, or clinical examination during macrostimulation to secure lead positioning, remains challenging because the STN cannot be reliably visualized using the gold standard, T2-weighted imaging (T2WI) at 1.5 T. Thus, there is a need to improve imaging tools to better visualize the STN, optimize DBS lead implantation, and enlarge DBS diffusion.

METHODS

Gradient-echo sequences such as those used in T2WI suffer from higher distortions at higher magnetic fields than spin-echo sequences. First, a spin-echo 3D SPACE (sampling perfection with application-optimized contrasts using different flip angle evolutions) FLAIR sequence at 3 T was designed, validated histologically in 2 nonhuman primates, and applied to 10 patients with PD; their data were clinically compared in a double-blind manner with those of a control group of 10 other patients with PD in whom STN targeting was performed using T2WI.

RESULTS

Overlap between the nonhuman primate STNs segmented on 3D-histological and on 3D-SPACE-FLAIR volumes was high for the 3 most anterior quarters (mean [± SD] Dice scores 0.73 ± 0.11, 0.74 ± 0.06, and 0.60 ± 0.09). STN limits determined by the 3D-SPACE-FLAIR sequence were more consistent with electrophysiological edges than those determined by T2WI (0.9 vs 1.4 mm, respectively). The imaging contrast of the STN on the 3D-SPACE-FLAIR sequence was 4 times higher (p < 0.05). Improvement in the Unified Parkinson's Disease Rating Scale Part III score (off medication, on stimulation) 12 months after the operation was higher for patients who underwent 3D-SPACE-FLAIR–guided implantation than for those in whom T2WI was used (62.2% vs 43.6%, respectively; p < 0.05). The total electrical energy delivered decreased by 36.3% with the 3D-SPACE-FLAIR sequence (p < 0.05).

CONCLUSIONS

3D-SPACE-FLAIR sequences at 3 T improved STN lead placement under stereotactic conditions, improved the clinical outcome of patients with PD, and increased the benefit/risk ratio of STN-DBS surgery.

ABBREVIATIONSDBS = deep brain stimulation; eSTN = electrophysiologically identified subthalamic nucleus; H&Y = Hoehn and Yahr; LEDD = levodopa equivalent daily dose; M12 = month 12 after implantation; NHP = nonhuman primate; PD = Parkinson's disease; SPACE = sampling perfection with application-optimized contrasts using different flip angle evolutions; STN = subthalamic nucleus; TEED = total electrical energy delivered; T1WI = T1-weighted imaging; T2WI = T2-weighted imaging; UPDRS = Unified Parkinson's Disease Rating Scale.
Article Information

Contributor Notes

INCLUDE WHEN CITING Published online January 8, 2016; DOI: 10.3171/2015.7.JNS15379.

Drs. Senova and Hosomi contributed equally to this work.

Correspondence Stéphane Palfi, Service de Neurochirurgie, CHU Henri Mondor, 51 Avenue du Marechal de Lattre de Tassigny, Créteil 94110, France. email: stephane.palfi@hmn.aphp.fr.

© AANS, except where prohibited by US copyright law.

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