Lack of agreement between direct magnetic resonance imaging and statistical determination of a subthalamic target: the role of electrophysiological guidance

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Object. The goal of this study was to determine the most suitable procedure(s) to localize the optimal site for high-frequency stimulation of the subthalamic nucleus (STN) for the treatment of advanced Parkinson disease.

Methods. Stereotactic coordinates of the STN were determined in 14 patients by using three different methods: direct identification of the STN on coronal and axial T2-weighted magnetic resonance (MR) images and indirect targeting in which the STN coordinates are referred to the anterior commissure—posterior commissure (AC—PC) line, which, itself, is determined either by using stereotactic ventriculography or reconstruction from three-dimensional (3D) MR images. During the surgical procedure, electrode implantation was guided by single-unit microrecordings on multiple parallel trajectories and by clinical assessment of stimulations. The site where the optimal functional response was obtained was considered to be the best target. Computerized tomography scanning was performed 3 days later and the scans were combined with preoperative 3D MR images to transfer the position of the best target to the same system of stereotactic coordinates. An algorithm was designed to convert individual stereotactic coordinates into an all-purpose PC-referenced system for comparing the respective accuracy of each method of targeting, according to the position of the best target.

Conclusions. The target that is directly identified by MR imaging is more remote (mainly in the lateral axis) from the site of the optimal functional response than targets obtained using other procedures, and the variability of this method in the lateral and superoinferior axes is greater. In contrast, the target defined by 3D MR imaging is closest to the target of optimal functional response and the variability of this method is the least great. Thus, 3D reconstruction adjusted to the AC—PC line is the most accurate technique for STN targeting, whereas direct visualization of the STN on MR images is the least effective. Electrophysiological guidance makes it possible to correct the inherent inaccuracy of the imaging and surgical techniques and is not designed to modify the initial targeting.

Article Information

Address reprint requests to: Emmanuel Cuny, M.D., Service de Neurochirurgie, Hôpital Pellegrin, CHU de Bordeaux, Place Amélie-Raba-Léon, 33076 Bordeaux, France. email: emmanuel.cuny@chu-bordeaux.fr.

© AANS, except where prohibited by US copyright law.

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Figures

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    The target is defined using ventriculography. A: Lateral teleradiographic view demonstrating the frame, scan box of the frame (Lines 2), and landmark of the point y = 100, z = 100 (Lines 1). B: Anterior teleradiographic demonstrating the frame, scan box of the frame (Lines 2), and landmark of the point x = 100, z = 100 (Lines 1). C and D: Lateral (C) and anterior (D) ventriculographic images demonstrating the AC—PC line and the statistically derived target. The Leksell target coordinates were determined by superimposition of the x-ray film in panel A with that in panel C, and the x-ray film in panel B with that in panel D. v = indirect target localization attained using ventriculography.

  • View in gallery

    Target is directly identified by MR imaging. A: Lateral (x axis) and superoinferior (z axis) directly identified using MR imaging coordinates of the STN are determined on coronal T2-weighted MR images obtained using the Leksell frame. B: The anteroposterior (y axis) coordinate of the target is determined by the anterior border (Line 1) of the red nucleus (RN).

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    Target defined by 3D MR imaging. A: Determination of the AC—PC line on the sagittal view of the T1-weighted 3D reconstruction. B: Target based on statistically derived coordinates.

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    Postoperative control of electrode placement. Axial view (A) and enlargement of this view (B) of the preoperative 3D MR image combined with the postoperative image (see the Leksell landmark in the periphery of the axial view (A). The postoperative CT scan is combined with the preoperative T1-weighted 3D MR image and the amount of contrast is minimized to allow only electrodes on the MR image to appear. It is then possible to represent the various contacts of the electrode and the various targets. This particular slice cuts through the target defined by ventriculography, the most posterior black point (v), and contact of the electrode, the most anterior black point (3).

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