Optimal location of thalamotomy lesions for tremor associated with Parkinson disease: a probabilistic analysis based on postoperative magnetic resonance imaging and an integrated digital atlas

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Object. Renewed interest in stereotactic neurosurgery for movement disorders has led to numerous reports of clinical outcomes associated with different treatment strategies. Nevertheless, there is a paucity of autopsy and imaging data that can be used to describe the optimal size and location of lesions or the location of implantable stimulators. In this study the authors correlated the clinical efficacy of stereotactic thalamotomy for tremor with precise anatomical localization by using postoperative magnetic resonance (MR) imaging and an integrated deformable digital atlas of subcortical structures.

Methods. Thirty-one lesions were created by stereotactic thalamotomy in 25 patients with tremor-dominant Parkinson disease. Lesion volume and configuration were evaluated by reviewing early postoperative MR images and were correlated with excellent, good, or fair tremor outcome categories. To allow valid comparisons of configurations of lesions with respect to cytoarchitectonic thalamic boundaries, the MR image obtained in each patient was nonlinearly deformed into a standardized MR imaging space, which included an integrated atlas of the basal ganglia and thalamus. The volume and precise location of lesions associated with different clinical outcomes were compared using nonparametric statistical methods. Probabilistic maps of lesions in each tremor outcome category were generated and compared.

Statistically significant differences in lesion location between excellent and good, and excellent and fair outcome categories were demonstrated. On average, lesions associated with excellent outcomes involved thalamic areas located more posteriorly than sites affected by lesions in the other two outcome groups. Subtraction analysis revealed that lesions correlated with excellent outcomes necessarily involved the interface of the nucleus ventralis intermedius (Vim; also known as the ventral lateral posterior nucleus [VLp]) and the nucleus ventrocaudalis (Vc; also known as the ventral posterior [VP] nucleus). Differences in lesion volume among outcome groups did not achieve statistical significance.

Conclusions. Anatomical evaluation of lesions within a standardized MR image—atlas integrated reference space is a useful method for determining optimal lesion localization. The results of an analysis of probabilistic maps indicates that optimal relief of tremor is associated with lesions involving the Vim (VLp) and the anterior Vc (VP).

Article Information

Address reprint requests to: Abbas F. Sadikot, M.D., Ph.D., Montreal Neurological Institute, 3801 University Avenue, Montreal, Quebec, H3A 2B4 Canada. email: sadikot@bic.mni.mcgill.ca.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Photographs of the leukotome loop at its maximum (7 mm, upper left) and intermediate (lower left) extensions. Right: Photographs showing the curved stimulating electrode at its maximum (14 mm, upper right) and intermediate (lower right) extension.

  • View in gallery

    Summary of the analysis procedure. A: Plates from the atlas of Schaltenbrand and Wahren91 (1) were previously digitized and integrated with a model MR image (MRI) that had a high signal-to-noise ratio (2). This set of steps was performed once. B: Subsequently, an MR image obtained in each patient was resampled to match the model MR image, based on the transformation generated by a nonlinear intensity-matching algorithm (1). Manually segmented lesions were then overlaid on the atlas and sorted into separate clinical outcome categories for statistical analysis (2).

  • View in gallery

    Graph showing mean lesion volumes by clinical outcome group. The differences are not statistically significant.

  • View in gallery

    Probabilistic maps for the three outcome categories—excellent, good, and fair—shown in axial slices centered at the coordinates of the center of mass of the essential lesion. The color bars at the right correspond to the probability of each pixel being represented in each lesion. The essential lesion represents a positive result of the pixel-wise subtraction of lesions from the good and fair outcome categories from the lesion from the excellent outcome category. GPe = globus pallidus externus. The essential lesion is necessary, but may not be sufficient for an excellent clinical outcome.

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