Implantation of deep brain stimulators into subthalmic nucleus: technical approach and magnetic imaging—verified electrode locations

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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.

Article Information

Address reprint requests to: Philip A. Starr, M.D., Ph.D., Department of Neurological Surgery, University of California at San Francisco, 779 Moffitt Hospital, 505 Parnassus Avenue, San Francisco, California 94143. email: starrp@itsa.ucsf.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Stereotactic targeting with reference to the commissures. A volumetrically acquired gradient-echo sequence is depicted (parameters are shown in Table 1), computationally reformatted to align with the intercommissural line and the midsagittal plane. The cross indicates the target with respect to the midcommissural point (lateral 12 mm, AP −3 mm, and vertical −3 mm). A: Axial plane. B: Coronal plane. The SNr is seen slightly inferior and medial to the target. C: Sagittal plane. D: Navigational view in the plane of the actual trajectory, showing the approach, which was planned to avoid traversing sulci or the lateral ventricle.

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    Stereotactic targeting by reference to the STN. A coronally oriented T2-weighted FSE sequence is displayed (parameters are shown in Table 1) at points 10 mm (A), 12 mm (B), and 14 mm (C) anterior to the PC. The arrows indicate the STN. The image in panel B was used for actual target selection.

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    Representative MERs in various nuclei along a trajectory (dotted line) through the STN. The drawing is a parasagittal section adapted from the Schaltenbrand and Wahren human brain atlas. Each trace is 1 second long. Upper Left: Dorsal thalamic bursting cell. Right: Three recordings made in the STN. Lower Left: Recording made in the SNr.

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    Modification of the initial anatomical target by MER in four illustrative cases. The column containing drawings shows data derived from MER. The microelectrode tracks (dotted lines) are superimposed on a drawing of the STN derived from the closest available parasagittal plane of the Schaltenbrand and Wahren atlas. Tracks are labeled T1 through T4 according to the order in which they were made; the numbers in parentheses represent the AP and lateral positions in millimeters, respectively, with regard to the initial anatomical target (positive direction defined as anterior and lateral). Segments are shaded according to the corresponding cellular activity that was recorded: gray represents the STN, black the SNr, and unshaded the red nucleus. Movement-related cells are shown as triangles (leg related) or circles (arm related). Microstimulation thresholds (stim) are indicated where a positive result was obtained and labeled according to the current threshold in microamperes for the observed effect as well as the body part whose motion was observed. The column containing grids shows a schematic in the axial plane of the locations of each microelectrode track (labeled T1 through T4) and of the final lead placement (L). The grid lines are drawn every 2 mm. Ant, Post, Med, and Lat indicate the anterior, posterior, medial, and lateral directions. The last column contains postoperative axial FSE MR images (parameters shown in Table 1) obtained 4 mm inferior to the commissures. The lead corresponding to the case described is indicated by an arrow. Note that in some cases, there is a contralateral lead that had been placed during a previous operation.

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    Postoperative gradient-echo MR images demonstrating the locations of the lead tip and entry point. The images have been computationally reformatted to align with the intercommissural line and midsagittal plane. A–C: Lead tip (arrow) in axial, coronal, and sagittal planes, respectively. Note that the tip was placed in the ventral STN; the active contact in this case was Contact 1, centered 3.75 mm rostral to the lead tip. D–F: A point on the lead near its entry into the brain (arrow) in axial, coronal, and sagittal planes, respectively.

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    Graphs of lead locations with respect to the AC—PC midpoint. Upper and Lower Left: Each symbol represents the mid-point of the quadripolar contact array. Upper and Lower Right: Each symbol represents the midpoint of the active contact or contacts after programming for optimal benefit.

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    Lead locations plotted with respect to a drawing adapted from the Schaltenbrand and Wahren atlas depicting the area 4 mm inferior to the AC. Locations were plotted based on the distance of the contact array from the midline and the distance anterior to the center of the red nucleus, as determined on postoperative axial FSE MR images obtained 4 mm inferior to the commissures. The symbols indicate the type of adverse effect that occurred at the lowest voltage threshold during intraoperative test stimulation, which was performed in bipolar mode by using the two contacts spanning the STN at 185 Hz. The arrow indicates an outlier lead that was documented to produce no improvement in the postoperative UPDRS motor score.

References

  • 1.

    Alexander GECrutcher MDDeLong MR: Basal gangliathalamocortical circuits: parallel substrates for motor, oculomotor, “prefrontal” and “limbic” functions. Prog Brain Res 85:1191461990Alexander GE Crutcher MD DeLong MR: Basal gangliathalamocortical circuits: parallel substrates for motor oculomotor “prefrontal” and “limbic” functions. Prog Brain Res 85:119–146 1990

    • Search Google Scholar
    • Export Citation
  • 2.

    Ashby PKim YJKumar Ret al: Neurophysiological effects of stimulation through electrodes in the human subthalamic nucleus. Brain 122:191919311999Ashby P Kim YJ Kumar R et al: Neurophysiological effects of stimulation through electrodes in the human subthalamic nucleus. Brain 122:1919–1931 1999

    • Search Google Scholar
    • Export Citation
  • 3.

    Barlas OHanagasi HAImer Met al: Do unilateral ablative lesions of the subthalamic nucleus in parkinsonian patients lead to hemiballism? Mov Disord 16:3063102001Barlas 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

    • Search Google Scholar
    • Export Citation
  • 4.

    Bejjani BDamier PArnulf Iet al: Transient acute depression induced by high-frequency deep-brain stimulation. N Engl J Med 340:147614801999Bejjani 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

    • Search Google Scholar
    • Export Citation
  • 5.

    Bejjani BPDormont DPidoux Bet al: Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg 92:6156252000Bejjani 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

    • Search Google Scholar
    • Export Citation
  • 6.

    Benabid ALBenazzouz AGao Det 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 5:5301999Benabid 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

    • Search Google Scholar
    • Export Citation
  • 7.

    Benabid ALPollak PGao Det al: Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg 84:2032141996Benabid 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

    • Search Google Scholar
    • Export Citation
  • 8.

    Bereznai BSteude USeelos Ket 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 17:1381442002Bereznai 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

    • Search Google Scholar
    • Export Citation
  • 9.

    Bergman HWichmann TDeLong MR: Reversal of experimental parkinsonism by lesions of the subthalamic nucleus. Science 249:143614381990Bergman H Wichmann T DeLong MR: Reversal of experimental parkinsonism by lesions of the subthalamic nucleus. Science 249:1436–1438 1990

    • Search Google Scholar
    • Export Citation
  • 10.

    Burchiel KJAnderson VCFavre Jet al: Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinson's disease: results of a randomized, blinded pilot study. Neurosurgery 45:137513841999Burchiel 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

    • Search Google Scholar
    • Export Citation
  • 11.

    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 345:9569632001Deep 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

    • Search Google Scholar
    • Export Citation
  • 12.

    DeLong MR: Primate models of movement disorders of basal ganglia origin. Trends Neurosci 13:2812851990DeLong MR: Primate models of movement disorders of basal ganglia origin. Trends Neurosci 13:281–285 1990

    • Search Google Scholar
    • Export Citation
  • 13.

    DeLong MRCrutcher MDGeorgopoulos AP: Primate globus pallidus and subthalamic nucleus: functional organization. J Neurophysiol 53:5305431985DeLong MR Crutcher MD Georgopoulos AP: Primate globus pallidus and subthalamic nucleus: functional organization. J Neurophysiol 53:530–543 1985

    • Search Google Scholar
    • Export Citation
  • 14.

    Drayer BBurger PDarwin Ret al: MRI of brain iron. AJR 147:1031101986Drayer B Burger P Darwin R et al: MRI of brain iron. AJR 147:103–110 1986

    • Search Google Scholar
    • Export Citation
  • 15.

    Favre JTaha JMSteel Tet al: Anchoring of deep brain stimulation electrodes using a microplate. Technical note. J Neurosurg 85:118111831996Favre J Taha JM Steel T et al: Anchoring of deep brain stimulation electrodes using a microplate. Technical note. J Neurosurg 85:1181–1183 1996

    • Search Google Scholar
    • Export Citation
  • 16.

    Felice KJKeilson GRSchwartz WJ: “Rubral” gait ataxia. Neurology 40:100410051990Felice KJ Keilson GR Schwartz WJ: “Rubral” gait ataxia. Neurology 40:1004–1005 1990

    • Search Google Scholar
    • Export Citation
  • 17.

    Giller CADewey RBGinsburg MIet al: Stereotactic pallidotomy and thalamotomy using individual variations of anatomic landmarks for localization. Neurosurgery 42:56651998Giller CA Dewey RB Ginsburg MI et al: Stereotactic pallidotomy and thalamotomy using individual variations of anatomic landmarks for localization. Neurosurgery 42:56–65 1998

    • Search Google Scholar
    • Export Citation
  • 18.

    Guridi JGorospe ARamos Eet al: Stereotactic targeting of the globus pallidus internus in Parkinson's disease: imaging versus electrophysiological mapping. Neurosurgery 45:2782891999Guridi 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

    • Search Google Scholar
    • Export Citation
  • 19.

    Hall WALiu HMartin AJet al: Brain biopsy sampling by using prospective stereotaxis and a trajectory guide. J Neurosurg 94:67712001Hall WA Liu H Martin AJ et al: Brain biopsy sampling by using prospective stereotaxis and a trajectory guide. J Neurosurg 94:67–71 2001

    • Search Google Scholar
    • Export Citation
  • 20.

    Hall WAMartin AJLiu Het al: Brain biopsy using high-field strength interventional magnetic resonance imaging. Neurosurgery 44:8078141999Hall WA Martin AJ Liu H et al: Brain biopsy using high-field strength interventional magnetic resonance imaging. Neurosurgery 44:807–814 1999

    • Search Google Scholar
    • Export Citation
  • 21.

    Hikosaka OWurtz RH: Visual and oculomotor functions of monkey substantia nigra pars reticulata. I. Relation of visual and auditory responses to saccades. J Neurophysiol 49:123012531983Hikosaka 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

    • Search Google Scholar
    • Export Citation
  • 22.

    Hutchison WD: Microelectrode techniques and findings of globus pallidus in Krauss JKGrossman RGJankovic J (eds): Pallidal Surgery for the Treatment of Parkinson's Disease and Movement Disorders. Philadelphia: Lippincott-Raven1998 pp 135152Hutchison 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

    • Search Google Scholar
    • Export Citation
  • 23.

    Hutchison WDAllan RJOpitz Het al: Neurophysiological identification of the subthalamic nucleus in surgery for Parkinson's disease. Ann Neurol 44:6226281998Hutchison 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

    • Search Google Scholar
    • Export Citation
  • 24.

    Krack PKumar RArdouin Cet al: Mirthful laughter induced by subthalamic nucleus stimulation. Mov Disord 16:8678752001Krack P Kumar R Ardouin C et al: Mirthful laughter induced by subthalamic nucleus stimulation. Mov Disord 16:867–875 2001

    • Search Google Scholar
    • Export Citation
  • 25.

    Krack PPollak PLimousin Pet al: From off-period dystonia to peak-dose chorea: the clinical spectrum of varying subthalamic nucleus activity. Brain 122:113311461999Krack 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

    • Search Google Scholar
    • Export Citation
  • 26.

    Kumar RLozano AMKim YJet al: Double-blind evaluation of subthalamic nucleus deep brain stimulation in advanced Parkinson's disease. Neurology 51:8508551998Kumar 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

    • Search Google Scholar
    • Export Citation
  • 27.

    Kumar RLozano AMSime Eet al: Comparative effects of unilateral and bilateral subthalamic nucleus deep brain stimulation. Neurology 53:5615661999Kumar R Lozano AM Sime E et al: Comparative effects of unilateral and bilateral subthalamic nucleus deep brain stimulation. Neurology 53:561–566 1999

    • Search Google Scholar
    • Export Citation
  • 28.

    Levy RHutchison WDLozano AMet al: High-frequency synchronization of neuronal activity in the subthalamic nucleus of parkinsonian patients with limb tremor. J Neurosci 20:776677752000Levy 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

    • Search Google Scholar
    • Export Citation
  • 29.

    Limousin PKrack PPollak Pet al: Electrical stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 339:110511111998Limousin 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

    • Search Google Scholar
    • Export Citation
  • 30.

    Maciunas RJGalloway RL JrLatimer JW: The application accuracy of stereotactic frames. Neurosurgery 35:6826951994Maciunas RJ Galloway RL Jr Latimer JW: The application accuracy of stereotactic frames. Neurosurgery 35:682–695 1994

    • Search Google Scholar
    • Export Citation
  • 31.

    Magnin MMorel AJeanmonod D: Single-unit analysis of the pallidum, thalamus and subthalamic nucleus in Parkinsonian patients. Neuroscience 96:5495642000Magnin M Morel A Jeanmonod D: Single-unit analysis of the pallidum thalamus and subthalamic nucleus in Parkinsonian patients. Neuroscience 96:549–564 2000

    • Search Google Scholar
    • Export Citation
  • 32.

    Montgomery EB JrBaker KB: Mechanisms of deep brain stimulation and future technical developments. Neurol Res 22:2592662000Montgomery EB Jr Baker KB: Mechanisms of deep brain stimulation and future technical developments. Neurol Res 22:259–266 2000

    • Search Google Scholar
    • Export Citation
  • 33.

    Morel AMagnin MJeanmonod D: Multiarchitectonic and stereotactic atlas of the human thalamus. J Comp Neurol 387:5886301997Morel A Magnin M Jeanmonod D: Multiarchitectonic and stereotactic atlas of the human thalamus. J Comp Neurol 387:588–630 1997

    • Search Google Scholar
    • Export Citation
  • 34.

    Moriarty TMQuinones-Hinojosa ALarson PSet al: Frameless stereotactic neurosurgery using intraoperative magnetic resonance imaging: stereotactic brain biopsy. Neurosurgery 47:113811462000Moriarty TM Quinones-Hinojosa A Larson PS et al: Frameless stereotactic neurosurgery using intraoperative magnetic resonance imaging: stereotactic brain biopsy. Neurosurgery 47:1138–1146 2000

    • Search Google Scholar
    • Export Citation
  • 35.

    Moro EScerrati MRomito LMet al: Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson's disease. Neurology 53:85901999Moro E Scerrati M Romito LM et al: Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson's disease. Neurology 53:85–90 1999

    • Search Google Scholar
    • Export Citation
  • 36.

    Ranck JB Jr: Which elements are excited in electrical stimulation of mammalian central nervous system: a review. Brain Res 98:4174401975Ranck JB Jr: Which elements are excited in electrical stimulation of mammalian central nervous system: a review. Brain Res 98:417–440 1975

    • Search Google Scholar
    • Export Citation
  • 37.

    Rezai ARHutchison WLozano AM: Chronic subthalamic nucleus stimulation for Parkinson's disease in Rengachary SSWilkins RH (eds): Neurosurgical Operative Atlas. Park Ridge, IL: American Association of Neurological Surgeons1999 Vol 8 pp 195207Rezai 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

    • Search Google Scholar
    • Export Citation
  • 38.

    Rezai ARLozano AMCrawley APet al: Thalamic stimulation and functional magnetic resonance imaging: localization of cortical and subcortical activation with implanted electrodes. Technical note. J Neurosurg 90:5835901999Rezai 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

    • Search Google Scholar
    • Export Citation
  • 39.

    Rodriguez MCGuridi OJAlvarez Let al: The subthalamic nucleus and tremor in Parkinson's disease. Mov Disord 13 (Suppl 3):1111181998Rodriguez MC Guridi OJ Alvarez L et al: The subthalamic nucleus and tremor in Parkinson's disease. Mov Disord 13 (Suppl 3):111–118 1998

    • Search Google Scholar
    • Export Citation
  • 40.

    Rodriguez-Oroz MCRodriguez MGonzalez Set al: Neuronal activity in the red nucleus in Parkinson's disease. Mov Disord 15 (Suppl 3): 652000 (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)

    • Search Google Scholar
    • Export Citation
  • 41.

    Rodriguez-Oroz MCRodriguez MGuridi Jet al: The subthalamic nucleus in Parkinson' s disease: somatotopic organization and physiological characteristics. Brain 124:177717902001Rodriguez-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

    • Search Google Scholar
    • Export Citation
  • 42.

    Schaltenbrand GWahren W: Atlas for Stereotaxy of the Human Brained 2. Stuttgart: Georg Thieme1977Schaltenbrand G Wahren W: Atlas for Stereotaxy of the Human Brain ed 2. Stuttgart: Georg Thieme 1977

    • Search Google Scholar
    • Export Citation
  • 43.

    Starr PASubramanian TBakay RAEet al: Electrophysiological localization of the substantia nigra in the parkinsonian nonhuman primate. J Neurosurg 93:7047102000Starr PA Subramanian T Bakay RAE et al: Electrophysiological localization of the substantia nigra in the parkinsonian nonhuman primate. J Neurosurg 93:704–710 2000

    • Search Google Scholar
    • Export Citation
  • 44.

    Starr PAVitek JLDeLong Met al: Magnetic resonance imaging-based stereotactic localization of the globus pallidus and subthalamic nucleus. Neurosurgery 44:3033141999Starr 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

    • Search Google Scholar
    • Export Citation
  • 45.

    Sterio DZonenshayn MMogilner AYet al: Neurophysiological refinement of subthalamic nucleus targeting. Neurosurgery 50:58692002Sterio D Zonenshayn M Mogilner AY et al: Neurophysiological refinement of subthalamic nucleus targeting. Neurosurgery 50:58–69 2002

    • Search Google Scholar
    • Export Citation
  • 46.

    Sumanaweera TSAdler JR JrNapel Set al: Characterization of spatial distortion in magnetic resonance imaging and its implications for stereotactic surgery. Neurosurgery 35:6967041994Sumanaweera 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

    • Search Google Scholar
    • Export Citation
  • 47.

    Theodosopoulos PVMarks W JrChristine Cet al: Physiology and functional organization of the human subthalamic nucleus. Mov Disord 15 (Suppl 3): 432000 (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)

    • Search Google Scholar
    • Export Citation
  • 48.

    Tronnier VMStaubert AHahnel Set al: Magnetic resonance imaging with implanted neurostimulators: an in vitro and in vivo study. Neurosurgery 44:1181261999Tronnier 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

    • Search Google Scholar
    • Export Citation
  • 49.

    Vidailhet MJedynak CPPollak Pet al: Pathology of symptomatic tremors. Mov Disord 13 (Suppl 3):49541998Vidailhet M Jedynak CP Pollak P et al: Pathology of symptomatic tremors. Mov Disord 13 (Suppl 3):49–54 1998

    • Search Google Scholar
    • Export Citation
  • 50.

    Vlaardingerbroek MTden Boer JA: Magnetic Resonance Imaging Theory and Practice. Berlin: Springer-Verlag1996 pp 107113Vlaardingerbroek MT den Boer JA: Magnetic Resonance Imaging Theory and Practice. Berlin: Springer-Verlag 1996 pp 107–113

    • Search Google Scholar
    • Export Citation
  • 51.

    Voges JVolkmann JAllert Net 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 96:2692792002Voges 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

    • Search Google Scholar
    • Export Citation
  • 52.

    Volkmann JAllert NVoges Jet al: Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology 56:5485512001Volkmann J Allert N Voges J et al: Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology 56:548–551 2001

    • Search Google Scholar
    • Export Citation
  • 53.

    Walton LHampshire AForster DMCet al: A phantom study to assess the accuracy of stereotactic localization, using T1-weighted magnetic resonance imaging with the Leksell stereotactic system. Neurosurgery 38:1701781996Walton 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

    • Search Google Scholar
    • Export Citation
  • 54.

    Wichmann TBergman HDelong MR: The primate subthalamic nucleus. I. Functional properties in intact animals. J Neurophysiol 72:4945061994Wichmann T Bergman H Delong MR: The primate subthalamic nucleus. I. Functional properties in intact animals. J Neurophysiol 72:494–506 1994

    • Search Google Scholar
    • Export Citation
  • 55.

    Yelnik JDamier PBejjani BPet al: Functional mapping of the human globus pallidus: contrasting effect of stimulation in the internal and external pallidum in Parkinson's disease. Neuroscience 101:77872000Yelnik 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

    • Search Google Scholar
    • Export Citation
  • 56.

    Yokoyama TSugiyama KNishizawa Set al: Subthalamic nucleus stimulation for gait disturbance in Parkinson's disease. Neurosurgery 45:41491999Yokoyama T Sugiyama K Nishizawa S et al: Subthalamic nucleus stimulation for gait disturbance in Parkinson's disease. Neurosurgery 45:41–49 1999

    • Search Google Scholar
    • Export Citation
  • 57.

    Zonenshayn MRezai ARMogilner AYet al: Comparison of anatomic and neurophysiological methods for subthalamic nucleus targeting. Neurosurgery 47:2822942000Zonenshayn M Rezai AR Mogilner AY et al: Comparison of anatomic and neurophysiological methods for subthalamic nucleus targeting. Neurosurgery 47:282–294 2000

    • Search Google Scholar
    • Export Citation

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