Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) is an alternative to thalamic DBS for the treatment of essential tremor (ET). The dentato-rubro-thalamic tract (DRTT) has recently been proposed as the anatomical substrate underlying effective stimulation. For clinical purposes, depiction of the DRTT mainly depends on diffusion tensor imaging (DTI)–based tractography, which has some drawbacks. The objective of this study was to present an accurate targeting strategy for DBS of the PSA based on anatomical landmarks visible on MRI and to evaluate clinical effectiveness.
The authors performed a retrospective cohort study of a prospective series of 11 ET patients undergoing bilateral DBS of the PSA. The subthalamic nucleus and red nucleus served as anatomical landmarks to define the target point within the adjacent PSA on 3-T T2-weighted MRI. Stimulating contact (SC) positions with reference to the midcommissural point were analyzed and projected onto the stereotactic atlas of Morel. Postoperative outcome assessment after 6 and 12 months was based on change in Tremor Rating Scale (TRS) scores.
Actual target position corresponded to the intended target based on anatomical landmarks depicted on MRI. The total TRS score was reduced (improved) from 47.2 ± 15.7 to 21.3 ± 10.7 (p < 0.001). No severe complication occurred. The mean SC position projected onto the PSA at the margin of the cerebellothalamic fascicle and the zona incerta.
Targeting of the PSA based on anatomical landmarks representable on MRI is reliable and leads to accurate lead placement as well as good long-term clinical outcome.
ABBREVIATIONSAP = anteroposterior; DBS = deep brain stimulation; DRTT = dentato-rubro-thalamic tract; DTI = diffusion tensor imaging; ET = essential tremor; fct = cerebellothalamic fascicle; LAT = lateral; MER = microelectrode recording; MCP = midcommissural point; PSA = posterior subthalamic area; RaprL = prelemniscal radiation; ROI = region of interest; SC = stimulating contact; STN = subthalamic nucleus; TRS = Tremor Rating Scale; VERT = vertical; Vim = ventral intermediate nucleus; ZI = zona incerta.
Correspondence Andreas Nowacki: Inselspital, University Hospital Bern, University of Bern, Switzerland. firstname.lastname@example.org.
INCLUDE WHEN CITING Published online October 12, 2018; DOI: 10.3171/2018.4.JNS18373.
Disclosures Andreas Nowacki reports being invited to research meetings sponsored by Boston Scientific not related to the current work. Ines Debove reports receiving financial support from Boston Scientific not related to the current work. Frédéric Rossi reports receiving financial support from Medtronic not related to the current work. Michael Schüpbach reports consultant relationships with Medtronic, Boston Scientific, and Aleva. Claudio Pollo reports a consultant relationship with Boston Scientific.
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