Bilateral high-frequency stimulation in the subthalamic nucleus for the treatment of Parkinson disease: correlation of therapeutic effect with anatomical electrode position

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Object. The goal of this study was to relate the degree of clinical improvement and that of energy consumption to the anatomical position of electrode poles used for long-term stimulation.

Methods. The authors conducted a retrospective analysis of 15 consecutive patients in whom targeting of the subthalamic nucleus (STN) had been performed using ventriculography, three-dimensional (3D) magnetic resonance (MR) imaging, and 3D computerized tomography, together with macrostimulation and teleradiographic control of the electrode position. In these patients the follow-up period ranged from 6 to 12 months. Postoperative improvement in contralateral motor symptoms, which was assessed by assigning a lateralized motor subscore of the Unified Parkinson's Disease Rating Scale (UPDRS), and stimulus intensity required for optimal treatment results were correlated with the intracerebral position of the active electrode pole.

Bilateral high-frequency stimulation of the STN improved the UPDRS motor score during the medication-off period by an average of 60.5% compared with that at baseline. Repeated transfer of stereotactic coordinates from postoperative teleradiography to treatment-planning MR images documented the proper localization of the most distal electrode pole (pole 0) in the targeted STN. Nevertheless, in most cases the best clinical improvement was achieved using electrode poles that were located several millimeters above the electrode tip. If the relative improvement in motor symptoms was correlated with the required electrical energy for chronic stimulation, the best coefficient was observed for active electrode poles projecting onto white matter dorsal to the STN.

Conclusions. This observation makes blocking or activation of large fiber connections arising in the STN or running nearby more likely than electrical interference with cell bodies inside the STN. Anatomical correlates may be the pallidothalamic bundle (including Field H of Forel and the thalamic fascicle), the pallidosubthalamic tract, and/or the zona incerta.

Article Information

Address reprint requests to: Jürgen Voges, M.D., Department of Stereotactic and Functional Neurosurgery, University of Cologne, Joseph-Stelzmann-Strasse 9, 50924 Köln, Germany. email: j.voges@uni-koeln.de.

© AANS, except where prohibited by US copyright law.

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Figures

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    Demonstration of the value of CT—MR image fusion. The MR image is overlaid as a square on the stereotactic CT scan at the level of the ventricles. Left: The MR imaging-defined ventricle contour fits perfectly with the ventricle contour shown on the CT scan. Right: Through image fusion the STN is visualized on T2-weighted images within the stereotactic coordinate system.

  • View in gallery

    Magnetic resonance images demonstrating intraoperative treatment planning. The trajectories are displayed in coronal (upper left), sagittal (lower left), and axial (upper and lower right) reconstructions with lines representing the projection of the trajectory onto the respective plane. Crosses indicate the intersection of the probe. In this case the proper localization of the most distal pole (pole 0, white crosses in upper right) of the quadripolar electrode inside the STN is documented on the transverse section. The second cross proximal to pole 0 (arrows in lower right) represents the electrode pole that has ultimately been used for successful chronic stimulation.

  • View in gallery

    The projection of all investigated quadripolar leads onto sagittal slices displayed in the Schaltenbrand atlas. The laterality is chosen based on coordinates of the active contact, which is displayed enlarged and color coded. The color code indicates the relative improvement in the contralateral UPDRS motor subscore in the medication-off period with chronic stimulation compared with that observed during the baseline examination.

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    Graphic comparison of the UPDRS motor score during the medication-off period before surgery and at the last follow-up examination with stimulation turned on. The horizontal bars indicate group mean values.

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    Bar graph showing a comparison between clinical improvement and stimulation efficacy for long-term stimulation of different subthalamic compartments based on MR imaging criteria: at active electrode poles located within subthalamic fibers (six poles), within the STN (three poles), and at the interface between the dorsal STN and fiber tracts (19 poles). Bars represent group median values of the proportional improvement in the UPDRS motor score after surgery during the medication-off period (white bars) and of the proportional improvement in UPDRS score per energy unit (gray bars).

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