Object. Chronic deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a procedure that is rapidly gaining acceptance for the treatment of symptoms in patients with Parkinson disease (PD), but there are few detailed descriptions of the surgical procedure itself. The authors present the technical approach used to implant 76 stimulators into the STNs of patients with PD and the lead locations, which were verified on postoperative magnetic resonance (MR) images.
Methods. Implantation procedures were performed with the aid of stereotactic MR imaging, microelectrode recording (MER) in the region of the stereotactic target to define the motor area of the STN, and intraoperative test stimulation to assess the thresholds for stimulation-induced adverse effects. All patients underwent postoperative MR imaging, which was performed using volumetric gradient-echo and T2-weighted fast—spin echo techniques, computational reformatting of the MR image into standard anatomical planes, and quantitative measurements of lead location with respect to the midcommissural point and the red nucleus. Lead locations were statistically correlated with physiological data obtained during MER and intraoperative test stimulation.
Conclusions. The authors' approach to implantation of DBS leads into the STN was associated with consistent lead placement in the dorsolateral STN, a low rate of morbidity, efficient use of operating room time, and robust improvement in motor function. The mean coordinates of the middle of the electrode array, measured on postoperative MR images, were 11.6 mm lateral, 2.9 mm posterior, and 4.7 mm inferior to the midcommissural point, and 6.5 mm lateral and 3.5 mm anterior to the center of the red nucleus. Voltage thresholds for several types of stimulation-induced adverse effects were predictive of lead location. Technical nuances of the surgery are described in detail.
Alexander GE, , Crutcher MD, & DeLong MR: Basal gangliathalamocortical circuits: parallel substrates for motor, oculomotor, “prefrontal” and “limbic” functions. Prog Brain Res 85:119–146, 1990 Alexander GE, Crutcher MD, DeLong MR: Basal gangliathalamocortical circuits: parallel substrates for motor, oculomotor, “prefrontal” and “limbic” functions. Prog Brain Res 85:119–146, 1990
Ashby P, , Kim YJ, & Kumar R, et al: Neurophysiological effects of stimulation through electrodes in the human subthalamic nucleus. Brain 122:1919–1931, 1999 Ashby P, Kim YJ, Kumar R, et al: Neurophysiological effects of stimulation through electrodes in the human subthalamic nucleus. Brain 122:1919–1931, 1999
Barlas O, , Hanagasi HA, & Imer M, et al: Do unilateral ablative lesions of the subthalamic nucleus in parkinsonian patients lead to hemiballism? Mov Disord 16:306–310, 2001 Barlas O, Hanagasi HA, Imer M, et al: Do unilateral ablative lesions of the subthalamic nucleus in parkinsonian patients lead to hemiballism? Mov Disord 16:306–310, 2001
Bejjani B, , Damier P, & Arnulf I, et al: Transient acute depression induced by high-frequency deep-brain stimulation. N Engl J Med 340:1476–1480, 1999 Bejjani B, Damier P, Arnulf I, et al: Transient acute depression induced by high-frequency deep-brain stimulation. N Engl J Med 340:1476–1480, 1999
Bejjani BP, , Dormont D, & Pidoux B, et al: Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg 92:615–625, 2000 Bejjani BP, Dormont D, Pidoux B, et al: Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg 92:615–625, 2000
Benabid AL, , Benazzouz A, & Gao D, et al: Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus and of other nuclei as a treatment for Parkinson's disease. Tech Neurosurg 5:5–30, 1999 Benabid AL, Benazzouz A, Gao D, et al: Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus and of other nuclei as a treatment for Parkinson's disease. Tech Neurosurg 5:5–30, 1999
Benabid AL, , Pollak P, & Gao D, et al: Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg 84:203–214, 1996 Benabid AL, Pollak P, Gao D, et al: Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg 84:203–214, 1996
Bereznai B, , Steude U, & Seelos K, et al: Chronic high-frequency globus pallidus internus stimulation in different types of dystonia: a clinical, video, and MR report of six patients presenting with segmental, cervical, and generalized dystonia. Mov Disord 17:138–144, 2002 Bereznai B, Steude U, Seelos K, et al: Chronic high-frequency globus pallidus internus stimulation in different types of dystonia: a clinical, video, and MR report of six patients presenting with segmental, cervical, and generalized dystonia. Mov Disord 17:138–144, 2002
Bergman H, , Wichmann T, & DeLong MR: Reversal of experimental parkinsonism by lesions of the subthalamic nucleus. Science 249:1436–1438, 1990 Bergman H, Wichmann T, DeLong MR: Reversal of experimental parkinsonism by lesions of the subthalamic nucleus. Science 249:1436–1438, 1990
Burchiel KJ, , Anderson VC, & Favre J, et al: Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinson's disease: results of a randomized, blinded pilot study. Neurosurgery 45:1375–1384, 1999 Burchiel KJ, Anderson VC, Favre J, et al: Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinson's disease: results of a randomized, blinded pilot study. Neurosurgery 45:1375–1384, 1999
Deep Brain Stimulation for Parkinson's Disease Study Group: Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's diseasee. N Engl J Med 345:956–963, 2001 Deep Brain Stimulation for Parkinson's Disease Study Group: Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's diseasee. N Engl J Med 345:956–963, 2001
DeLong MR: Primate models of movement disorders of basal ganglia origin. Trends Neurosci 13:281–285, 1990 DeLong MR: Primate models of movement disorders of basal ganglia origin. Trends Neurosci 13:281–285, 1990
DeLong MR, , Crutcher MD, & Georgopoulos AP: Primate globus pallidus and subthalamic nucleus: functional organization. J Neurophysiol 53:530–543, 1985 DeLong MR, Crutcher MD, Georgopoulos AP: Primate globus pallidus and subthalamic nucleus: functional organization. J Neurophysiol 53:530–543, 1985
Drayer B, , Burger P, & Darwin R, et al: MRI of brain iron. AJR 147:103–110, 1986 Drayer B, Burger P, Darwin R, et al: MRI of brain iron. AJR 147:103–110, 1986
Favre J, , Taha JM, & Steel T, et al: Anchoring of deep brain stimulation electrodes using a microplate. Technical note. J Neurosurg 85:1181–1183, 1996 Favre J, Taha JM, Steel T, et al: Anchoring of deep brain stimulation electrodes using a microplate. Technical note. J Neurosurg 85:1181–1183, 1996
Felice KJ, , Keilson GR, & Schwartz WJ: “Rubral” gait ataxia. Neurology 40:1004–1005, 1990 Felice KJ, Keilson GR, Schwartz WJ: “Rubral” gait ataxia. Neurology 40:1004–1005, 1990
Giller CA, , Dewey RB, & Ginsburg MI, et al: Stereotactic pallidotomy and thalamotomy using individual variations of anatomic landmarks for localization. Neurosurgery 42:56–65, 1998 Giller CA, Dewey RB, Ginsburg MI, et al: Stereotactic pallidotomy and thalamotomy using individual variations of anatomic landmarks for localization. Neurosurgery 42:56–65, 1998
Guridi J, , Gorospe A, & Ramos E, et al: Stereotactic targeting of the globus pallidus internus in Parkinson's disease: imaging versus electrophysiological mapping. Neurosurgery 45:278–289, 1999 Guridi J, Gorospe A, Ramos E, et al: Stereotactic targeting of the globus pallidus internus in Parkinson's disease: imaging versus electrophysiological mapping. Neurosurgery 45:278–289, 1999
Hall WA, , Liu H, & Martin AJ, et al: Brain biopsy sampling by using prospective stereotaxis and a trajectory guide. J Neurosurg 94:67–71, 2001 Hall WA, Liu H, Martin AJ, et al: Brain biopsy sampling by using prospective stereotaxis and a trajectory guide. J Neurosurg 94:67–71, 2001
Hall WA, , Martin AJ, & Liu H, et al: Brain biopsy using high-field strength interventional magnetic resonance imaging. Neurosurgery 44:807–814, 1999 Hall WA, Martin AJ, Liu H, et al: Brain biopsy using high-field strength interventional magnetic resonance imaging. Neurosurgery 44:807–814, 1999
Hikosaka O, & Wurtz RH: Visual and oculomotor functions of monkey substantia nigra pars reticulata. I. Relation of visual and auditory responses to saccades. J Neurophysiol 49:1230–1253, 1983 Hikosaka O, Wurtz RH: Visual and oculomotor functions of monkey substantia nigra pars reticulata. I. Relation of visual and auditory responses to saccades. J Neurophysiol 49:1230–1253, 1983
Hutchison WD: Microelectrode techniques and findings of globus pallidus, in Krauss JK, , Grossman RG, & Jankovic J (eds): Pallidal Surgery for the Treatment of Parkinson's Disease and Movement Disorders. Philadelphia: Lippincott-Raven, 1998, pp 135–152 Hutchison WD: Microelectrode techniques and findings of globus pallidus, in Krauss JK, Grossman RG, Jankovic J (eds): Pallidal Surgery for the Treatment of Parkinson's Disease and Movement Disorders. Philadelphia: Lippincott-Raven, 1998, pp 135–152
Hutchison WD, , Allan RJ, & Opitz H, et al: Neurophysiological identification of the subthalamic nucleus in surgery for Parkinson's disease. Ann Neurol 44:622–628, 1998 Hutchison WD, Allan RJ, Opitz H, et al: Neurophysiological identification of the subthalamic nucleus in surgery for Parkinson's disease. Ann Neurol 44:622–628, 1998
Krack P, , Kumar R, & Ardouin C, et al: Mirthful laughter induced by subthalamic nucleus stimulation. Mov Disord 16:867–875, 2001 Krack P, Kumar R, Ardouin C, et al: Mirthful laughter induced by subthalamic nucleus stimulation. Mov Disord 16:867–875, 2001
Krack P, , Pollak P, & Limousin P, et al: From off-period dystonia to peak-dose chorea: the clinical spectrum of varying subthalamic nucleus activity. Brain 122:1133–1146, 1999 Krack P, Pollak P, Limousin P, et al: From off-period dystonia to peak-dose chorea: the clinical spectrum of varying subthalamic nucleus activity. Brain 122:1133–1146, 1999
Kumar R, , Lozano AM, & Kim YJ, et al: Double-blind evaluation of subthalamic nucleus deep brain stimulation in advanced Parkinson's disease. Neurology 51:850–855, 1998 Kumar R, Lozano AM, Kim YJ, et al: Double-blind evaluation of subthalamic nucleus deep brain stimulation in advanced Parkinson's disease. Neurology 51:850–855, 1998
Kumar R, , Lozano AM, & Sime E, et al: Comparative effects of unilateral and bilateral subthalamic nucleus deep brain stimulation. Neurology 53:561–566, 1999 Kumar R, Lozano AM, Sime E, et al: Comparative effects of unilateral and bilateral subthalamic nucleus deep brain stimulation. Neurology 53:561–566, 1999
Levy R, , Hutchison WD, & Lozano AM, et al: High-frequency synchronization of neuronal activity in the subthalamic nucleus of parkinsonian patients with limb tremor. J Neurosci 20:7766–7775, 2000 Levy R, Hutchison WD, Lozano AM, et al: High-frequency synchronization of neuronal activity in the subthalamic nucleus of parkinsonian patients with limb tremor. J Neurosci 20:7766–7775, 2000
Limousin P, , Krack P, & Pollak P, et al: Electrical stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 339:1105–1111, 1998 Limousin P, Krack P, Pollak P, et al: Electrical stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 339:1105–1111, 1998
Maciunas RJ, , Galloway RL Jr, & Latimer JW: The application accuracy of stereotactic frames. Neurosurgery 35:682–695, 1994 Maciunas RJ, Galloway RL Jr, Latimer JW: The application accuracy of stereotactic frames. Neurosurgery 35:682–695, 1994
Magnin M, , Morel A, & Jeanmonod D: Single-unit analysis of the pallidum, thalamus and subthalamic nucleus in Parkinsonian patients. Neuroscience 96:549–564, 2000 Magnin M, Morel A, Jeanmonod D: Single-unit analysis of the pallidum, thalamus and subthalamic nucleus in Parkinsonian patients. Neuroscience 96:549–564, 2000
Montgomery EB Jr, & Baker KB: Mechanisms of deep brain stimulation and future technical developments. Neurol Res 22:259–266, 2000 Montgomery EB Jr, Baker KB: Mechanisms of deep brain stimulation and future technical developments. Neurol Res 22:259–266, 2000
Morel A, , Magnin M, & Jeanmonod D: Multiarchitectonic and stereotactic atlas of the human thalamus. J Comp Neurol 387:588–630, 1997 Morel A, Magnin M, Jeanmonod D: Multiarchitectonic and stereotactic atlas of the human thalamus. J Comp Neurol 387:588–630, 1997
Moriarty TM, , Quinones-Hinojosa A, & Larson PS, et al: Frameless stereotactic neurosurgery using intraoperative magnetic resonance imaging: stereotactic brain biopsy. Neurosurgery 47:1138–1146, 2000 Moriarty TM, Quinones-Hinojosa A, Larson PS, et al: Frameless stereotactic neurosurgery using intraoperative magnetic resonance imaging: stereotactic brain biopsy. Neurosurgery 47:1138–1146, 2000
Moro E, , Scerrati M, & Romito LM, et al: Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson's disease. Neurology 53:85–90, 1999 Moro E, Scerrati M, Romito LM, et al: Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson's disease. Neurology 53:85–90, 1999
Ranck JB Jr: Which elements are excited in electrical stimulation of mammalian central nervous system: a review. Brain Res 98:417–440, 1975 Ranck JB Jr: Which elements are excited in electrical stimulation of mammalian central nervous system: a review. Brain Res 98:417–440, 1975
Rezai AR, , Hutchison W, & Lozano AM: Chronic subthalamic nucleus stimulation for Parkinson's disease, in Rengachary SS, & Wilkins RH (eds): Neurosurgical Operative Atlas. Park Ridge, IL: American Association of Neurological Surgeons, 1999, Vol 8, pp 195–207 Rezai AR, Hutchison W, Lozano AM: Chronic subthalamic nucleus stimulation for Parkinson's disease, in Rengachary SS, Wilkins RH (eds): Neurosurgical Operative Atlas. Park Ridge, IL: American Association of Neurological Surgeons, 1999, Vol 8, pp 195–207
Rezai AR, , Lozano AM, & Crawley AP, et al: Thalamic stimulation and functional magnetic resonance imaging: localization of cortical and subcortical activation with implanted electrodes. Technical note. J Neurosurg 90:583–590, 1999 Rezai AR, Lozano AM, Crawley AP, et al: Thalamic stimulation and functional magnetic resonance imaging: localization of cortical and subcortical activation with implanted electrodes. Technical note. J Neurosurg 90:583–590, 1999
Rodriguez MC, , Guridi OJ, & Alvarez L, et al: The subthalamic nucleus and tremor in Parkinson's disease. Mov Disord 13 (Suppl 3):111–118, 1998 Rodriguez MC, Guridi OJ, Alvarez L, et al: The subthalamic nucleus and tremor in Parkinson's disease. Mov Disord 13 (Suppl 3):111–118, 1998
Rodriguez-Oroz MC, , Rodriguez M, & Gonzalez S, et al: Neuronal activity in the red nucleus in Parkinson's disease. Mov Disord 15 (Suppl 3): 65, 2000 (Abstract) Rodriguez-Oroz MC, Rodriguez M, Gonzalez S, et al: Neuronal activity in the red nucleus in Parkinson's disease. Mov Disord 15 (Suppl 3): 65, 2000 (Abstract)
Rodriguez-Oroz MC, , Rodriguez M, & Guridi J, et al: The subthalamic nucleus in Parkinson' s disease: somatotopic organization and physiological characteristics. Brain 124:1777–1790, 2001 Rodriguez-Oroz MC, Rodriguez M, Guridi J, et al: The subthalamic nucleus in Parkinson' s disease: somatotopic organization and physiological characteristics. Brain 124:1777–1790, 2001
Schaltenbrand G, & Wahren W: Atlas for Stereotaxy of the Human Brain, ed 2. Stuttgart: Georg Thieme, 1977 Schaltenbrand G, Wahren W: Atlas for Stereotaxy of the Human Brain, ed 2. Stuttgart: Georg Thieme, 1977
Starr PA, , Subramanian T, & Bakay RAE, et al: Electrophysiological localization of the substantia nigra in the parkinsonian nonhuman primate. J Neurosurg 93:704–710, 2000 Starr PA, Subramanian T, Bakay RAE, et al: Electrophysiological localization of the substantia nigra in the parkinsonian nonhuman primate. J Neurosurg 93:704–710, 2000
Starr PA, , Vitek JL, & DeLong M, et al: Magnetic resonance imaging-based stereotactic localization of the globus pallidus and subthalamic nucleus. Neurosurgery 44:303–314, 1999 Starr PA, Vitek JL, DeLong M, et al: Magnetic resonance imaging-based stereotactic localization of the globus pallidus and subthalamic nucleus. Neurosurgery 44:303–314, 1999
Sterio D, , Zonenshayn M, & Mogilner AY, et al: Neurophysiological refinement of subthalamic nucleus targeting. Neurosurgery 50:58–69, 2002 Sterio D, Zonenshayn M, Mogilner AY, et al: Neurophysiological refinement of subthalamic nucleus targeting. Neurosurgery 50:58–69, 2002
Sumanaweera TS, , Adler JR Jr, & Napel S, et al: Characterization of spatial distortion in magnetic resonance imaging and its implications for stereotactic surgery. Neurosurgery 35:696–704, 1994 Sumanaweera TS, Adler JR Jr, Napel S, et al: Characterization of spatial distortion in magnetic resonance imaging and its implications for stereotactic surgery. Neurosurgery 35:696–704, 1994
Theodosopoulos PV, , Marks W Jr, & Christine C, et al: Physiology and functional organization of the human subthalamic nucleus. Mov Disord 15 (Suppl 3): 43, 2000 (Abstract) Theodosopoulos PV, Marks W Jr, Christine C, et al: Physiology and functional organization of the human subthalamic nucleus. Mov Disord 15 (Suppl 3): 43, 2000 (Abstract)
Tronnier VM, , Staubert A, & Hahnel S, et al: Magnetic resonance imaging with implanted neurostimulators: an in vitro and in vivo study. Neurosurgery 44:118–126, 1999 Tronnier VM, Staubert A, Hahnel S, et al: Magnetic resonance imaging with implanted neurostimulators: an in vitro and in vivo study. Neurosurgery 44:118–126, 1999
Vidailhet M, , Jedynak CP, & Pollak P, et al: Pathology of symptomatic tremors. Mov Disord 13 (Suppl 3):49–54, 1998 Vidailhet M, Jedynak CP, Pollak P, et al: Pathology of symptomatic tremors. Mov Disord 13 (Suppl 3):49–54, 1998
Vlaardingerbroek MT, & den Boer JA: Magnetic Resonance Imaging, Theory and Practice. Berlin: Springer-Verlag, 1996, pp 107–113 Vlaardingerbroek MT, den Boer JA: Magnetic Resonance Imaging, Theory and Practice. Berlin: Springer-Verlag, 1996, pp 107–113
Voges J, , Volkmann J, & Allert N, et al: Bilateral high-frequency stimulation in the subthalamic nucleus for the treatment of Parkinson disease: correlation of therapeutic effect with anatomical electrode position. J Neurosurg 96:269–279, 2002 Voges J, Volkmann J, Allert N, et al: Bilateral high-frequency stimulation in the subthalamic nucleus for the treatment of Parkinson disease: correlation of therapeutic effect with anatomical electrode position. J Neurosurg 96:269–279, 2002
Volkmann J, , Allert N, & Voges J, et al: Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology 56:548–551, 2001 Volkmann J, Allert N, Voges J, et al: Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology 56:548–551, 2001
Walton L, , Hampshire A, & Forster DMC, et al: A phantom study to assess the accuracy of stereotactic localization, using T1-weighted magnetic resonance imaging with the Leksell stereotactic system. Neurosurgery 38:170–178, 1996 Walton L, Hampshire A, Forster DMC, et al: A phantom study to assess the accuracy of stereotactic localization, using T1-weighted magnetic resonance imaging with the Leksell stereotactic system. Neurosurgery 38:170–178, 1996
Wichmann T, , Bergman H, & Delong MR: The primate subthalamic nucleus. I. Functional properties in intact animals. J Neurophysiol 72:494–506, 1994 Wichmann T, Bergman H, Delong MR: The primate subthalamic nucleus. I. Functional properties in intact animals. J Neurophysiol 72:494–506, 1994
Yelnik J, , Damier P, & Bejjani BP, et al: Functional mapping of the human globus pallidus: contrasting effect of stimulation in the internal and external pallidum in Parkinson's disease. Neuroscience 101:77–87, 2000 Yelnik J, Damier P, Bejjani BP, et al: Functional mapping of the human globus pallidus: contrasting effect of stimulation in the internal and external pallidum in Parkinson's disease. Neuroscience 101:77–87, 2000
Yokoyama T, , Sugiyama K, & Nishizawa S, et al: Subthalamic nucleus stimulation for gait disturbance in Parkinson's disease. Neurosurgery 45:41–49, 1999 Yokoyama T, Sugiyama K, Nishizawa S, et al: Subthalamic nucleus stimulation for gait disturbance in Parkinson's disease. Neurosurgery 45:41–49, 1999
Zonenshayn M, , Rezai AR, & Mogilner AY, et al: Comparison of anatomic and neurophysiological methods for subthalamic nucleus targeting. Neurosurgery 47:282–294, 2000 Zonenshayn M, Rezai AR, Mogilner AY, et al: Comparison of anatomic and neurophysiological methods for subthalamic nucleus targeting. Neurosurgery 47:282–294, 2000
All Time | Past Year | Past 30 Days | |
---|---|---|---|
Abstract Views | 1446 | 418 | 50 |
Full Text Views | 396 | 48 | 4 |
PDF Downloads | 223 | 32 | 3 |
EPUB Downloads | 0 | 0 | 0 |