Microelectrode-guided posteroventral pallidotomy for treatment of Parkinson's disease: postoperative magnetic resonance imaging analysis

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✓ The authors report the postoperative magnetic resonance (MR) imaging findings in 36 patients with advanced Parkinson's disease who underwent unilateral microelectrode-guided posteroventral pallidotomy. The lesions were placed within 1 mm of the ventral border of the globus pallidus internus (GPi) to include pallidothalamic outflow pathways. Sequential MR studies were obtained within 1 to 3 days postoperatively and at 6-month follow-up examination. Thirty-four (94%) of the 36 patients enjoyed sustained moderate or marked improvement of their parkinsonian symptoms 6 months postoperatively. Transient side effects occurred in five patients (14%), but there were no persistent complications. The pallidal radiofrequency lesions were prolate spheroid shaped and were composed of three concentric zones in the early postoperative studies. The mean volume of the middle zone, corresponding to the area of hemorrhagic coagulation necrosis, was 44.4 ± 17.6 mm3; the mean lesion volume as defined by the outer zone, corresponding to perilesional edema, was 262.2 ± 111.6 mm3. Additional edema spreading to the internal capsule was noted in 32 of 34 cases and to the optic tract in 11 of 34 cases. In two patients small ischemic infarctions involving the corona radiata were found, and in one a venous infarction was detected. Ischemic infarction resulted in mild transient Broca's aphasia in one patient, but there was no detectable neurological deficit in the other two. The mean volume of late-phase (6 months) lesions was 22 ± 28.8 mm3. In three patients no lesion was identified despite sustained clinical improvement. The lesion was located in the posteroventral GPi in all cases except in one patient in whom it was confined to the GP externus (GPe). This 49-year-old woman did not experience sustained benefit. The authors found no consistent correlations between lesion size and location and clinical outcome as measured by a global outcome score, the Unified Parkinson's Disease Rating Scale motor, activities of daily living, and bradykinesia “off” scores or rating of dyskinesias. Lesioning of pallidal and subpallidal pathways may contribute to the sustained clinical benefit in this series. Magnetic resonance imaging analysis showed that intraoperative microelectrode recording facilitated accurate placement of the lesion in this critical area.

Article Information

Address reprint requests to: Joachim K. Krauss, M.D., Department of Neurosurgery, Inselspital, University of Berne, 3010 Berne, Switzerland.

© AANS, except where prohibited by US copyright law.

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Figures

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    Magnetic resonance T2-weighted sequences obtained in a 58-year-old patient 2 days after a right-sided pallidotomy was performed. The sagittal (left), coronal (center), and axial (right) images demonstrate the elliptoid shape of the lesion and its three-zoned composition with a dotlike inner hyperintense zone, a hypointense middle zone, and a hyperintense outer zone.

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    Magnetic resonance images comparing different sequences obtained in a 60-year-old patient 1 day after a left-sided pallidotomy was performed. The three-zoned composition of the lesion is seen on an axial T2-weighted image (left), proton density—weighted image (center), and inversion recovery image (right).

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    Sagittal T2-weighted MR imaging sequence in a 40-year-old patient 2 days after a left-sided pallidotomy was performed. The image shows the proximity of the inferior margin of the hyperintense outer zone of the lesion to the optic tract.

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    Axial T2-weighted (left) and inversion recovery (right) MR sequences in a 50-year-old patient after a right-sided pallidotomy was performed. The lesion is confined to the medial pallidum, which is best shown on the inversion recovery sequences (compare with the morphology of the contralateral pallidum). Additional perilesional edema extends into the adjacent internal capsule.

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    Axial T2-weighted MR images obtained in a 67-year-old patient (left) and a 60-year-old patient (right) 2 days after left-sided pallidotomy. In both patients asymptomatic edema of the optic tract is detected.

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    Magnetic resonance T2-weighted sequences obtained in a 68-year-old patient 2 days (upper left and right) and 6 months (lower left and right) after a left-sided pallidotomy. The early sagittal (upper left) and axial (upper right) images show the incidental finding of an asymptomatic small ischemic infarction extending from the pallidal lesion area into the corona radiata. The lesion and the infarction are well demarcated on the sagittal (lower left) and axial (lower right) follow-up studies.

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    Magnetic resonance T2-weighted sequences obtained in a 51-year-old patient 6 months after a left-sided pallidotomy was performed. The axial (left) and sagittal (right) images show the hyperintense late-phase lesion and its proximity to the optic tract and choroidal fissure.

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    Axial FSPGR MR sequence obtained in a 66-year-old patient 6 months after a left-sided pallidotomy was performed. The pallidal lesion is well demarcated.

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    Magnetic resonance T2-weighted coronal (left) and proton density—weighted axial (right) sequences obtained in a 49-year-old patient 6 months after a right-sided pallidotomy. No persistent clinical benefit was achieved in this patient, with the late-phase lesion located completely within the lateral pallidum.

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