Targeting the posterior subthalamic area for essential tremor: proposal for MRI-based anatomical landmarks

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OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS AP = 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.

Article Information

Correspondence Andreas Nowacki: Inselspital, University Hospital Bern, University of Bern, Switzerland. neuro.nowacki@gmail.com.

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.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Targeting strategy for the PSA and determination of the distance between the SC and the center of gravity of the DRTT. The theoretical target point at the center of the PSA is based on the stereotactic atlas of Morel (A). The applied targeting strategy based on 3-T T2-weighted MRI sequences leads to the planned target (B). The distance between the SC and the center of the tractography-based DRTT (1.5 mm in this case) was measured with iPlan 3.0 software (C and D). al = ansa lenticularis; fct = cerebellothalmic fascicle; fl = fasciculus lenticularis; GPi = globus pallidus interna; ic = internal capsule; mcl = midcommissural line; MGN = medial geniculate nucleus; ml = medial lemniscus; mtt = mammillothalamic tract; PAG = periaqueductal gray; pc = posterior commissure; Po = posterior nucleus; RN = red nucleus; SG = suprageniculate nucleus; STh = subthalamic nucleus; VPI = ventral posterior inferior nucleus; VPMpc = ventral posterior medial nucleus, parvocellular division; ZI = zona incerta. Panel A modified from Gallay MN, Jeanmonod D, Liu J, Morel A: Human pallidothalamic and cerebellothalamic tracts: anatomical basis for functional stereotactic neurosurgery. Brain Struct Funct 212:443–463, 2008, with kind permission of the authors. Copyright the authors. CC BY-NC (https://creativecommons.org/licenses/by-nc/3.0/).

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    Box and whiskers plot showing the pre- and postoperative total scores and subscores from the Fahn-Tolosa-Marin Tremor Rating Scale (TRS). Part A scores improved from 14.3 ± 5.2 to 7 ± 4.7, part B scores improved from 19 ± 7.4 to 9.2 ± 4.6, and part C scores improved from 14.8 ± 4.9 to 4.8 ± 3.5 postoperatively. There was a statistically significant reduction of the total TRS and the 3 TRS subscores (p < 0.001; 2-way repeated measures ANOVA). The boxes indicate IQRs, the horizontal lines within the boxes indicate the median values, and the whiskers indicate the minimum and maximum values.

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    Mean target (A) and SC (B and C) position projected onto the stereotactic atlas of Morel. The mean target point (A) was slightly posterior to the theoretically expected target point according to MRI-based anatomical landmarks and projected onto the center of the PSA at the margin of the cerebellothalamic fascicle (fct) and zona incerta (ZI). The mean SC position was superior with respect to the planned target and projected onto the PSA at the margin of the fct and ZI on both axial (B) and sagittal (C) images. ft = fasciculus thalamicus; R = reticular thalamic nucleus; sPf = supraparafascicular nucleus; VApc = ventral anterior nucleus, parvocellular division; VLpv = ventral lateral posterior nucleus, ventral division; VPLp = ventral posterior lateral nucleus, posterior division; VPM = ventral posterior medial nucleus. Adapted from Gallay MN, Jeanmonod D, Liu J, Morel A: Human pallidothalamic and cerebellothalamic tracts: anatomical basis for functional stereotactic neurosurgery. Brain Struct Funct 212:443–463, 2008, with kind permission of the authors. Copyright the authors. CC BY-NC (https://creativecommons.org/licenses/by-nc/3.0/).

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    Comparison of the mean SC position. The stereotactic coordinates of the mean SC position of our results and those of other groups are projected onto the stereotactic atlas of Morel. Modified from Gallay MN, Jeanmonod D, Liu J, Morel A: Human pallidothalamic and cerebellothalamic tracts: anatomical basis for functional stereotactic neurosurgery. Brain Struct Funct 212:443–463, 2008, with kind permission of the authors. Copyright the authors. CC BY-NC (https://creativecommons.org/licenses/by-nc/3.0/).

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