Localization of stimulating electrodes in patients with Parkinson disease by using a three-dimensional atlas—magnetic resonance imaging coregistration method

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Object. The aim of this study was to correlate the clinical improvement in patients with Parkinson disease (PD) treated using deep brain stimulation (DBS) of the subthalamic nucleus (STN) with the precise anatomical localization of stimulating electrodes.

Methods. Localization was determined by superimposing figures from an anatomical atlas with postoperative magnetic resonance (MR) images obtained in each patient. This approach was validated by an analysis of experimental and clinical MR images of the electrode, and the development of a three-dimensional (3D) atlas—MR imaging coregistration method. The PD motor score was assessed through two contacts for each of two electrodes implanted in 10 patients: the “therapeutic contact” and the “distant contact” (that is, the next but one to the therapeutic contact). Seventeen therapeutic contacts were located within or on the border of the STN, most of which were associated with significant improvement of the four PD symptoms tested. Therapeutic contacts located in other structures (zona incerta, lenticular fasciculus, or midbrain reticular formation) were also linked to a significant positive effect. Stimulation applied through distant contacts located in the STN improved symptoms of PD, whereas that delivered through distant contacts in the remaining structures had variable effects ranging from worsening of symptoms to their improvement.

Conclusions. The authors have demonstrated that 3D atlas—MR imaging coregistration is a reliable method for the precise localization of DBS electrodes on postoperative MR images. In addition, they have confirmed that although the STN is the main target during DBS treatment for PD, stimulation of surrounding regions, particularly the zona incerta or the lenticular fasciculus, can also improve symptoms of PD.

Article Information

Address reprint requests to: Jerome Yelnik, M.D., INSERM U289, Hôpital de la Salpêtrière, 47, boulevard de l'Hôpital, 75013 Paris, France. email: yelnik@ccr.jussieu.fr.

© AANS, except where prohibited by US copyright law.

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Figures

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    Analysis of the MR image of the electrode. A: Magnetic resonance images demonstrating a quadripolar electrode placed within a glass tube that is maintained in a bowl of agarose frost. Three orthogonal sections of the image are shown. B: Two orthogonal sections of the MR image of the glass tube obtained after reformatting. The glass tube is vertically oriented. Note the indentations present along the tube. C: Two orthogonal sections of the MR image demonstrating the electrode placed in the glass tube. Note that the proximal portion (P) is cylindrical, whereas the terminal portion (T) is deformed. The blue and red lines in B and C intersect at the same voxel in the two synchronized images. D: An MR image demonstrating the extracted contours of the glass tube, which are traced in yellow. E: An MR image of the tube contours is superimposed onto an MR image of the electrode. Note that the proximal portion of the electrode fits exactly the image of the glass tube, whereas its terminal portion is larger. F: A postoperative MR image obtained after bilateral implantation of quadripolar electrodes into the STN. The proximal (P) and terminal (T) portions of the electrode are indicated (blue arrows). The MR image was obtained in an obliquely oriented slice containing the entire trajectory of the left electrode. The cylindrical hypointense signal at the tip of the electrode corresponds to the artifact induced by the four metallic contacts. G: An MR image of the right electrode in the same patient. Four indentations corresponding to the four contacts are indicated (blue arrows). H: An MR image displaying the left electrode in another patient. A 6-mm-long trace is superimposed on the terminal portion of the electrode. I: Schematic drawing of comparative dimensions (in millimeters) of the electrode and its artifact.

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    Contact identification and reformatting of the postoperative MR acquisition. A: An oblique MR image superimposed with a scaled template of the electrode in the prolongation of the axis of the proximal portion. The four consecutive contacts (0, 1, 2, and 3) are identified. B: A sagittal MR image revealing a section of the AC and PC points from which the horizontal plane is defined. The AC—PC line made a 38° angle with the axial acquisition plane. Four horizontal slices (1, 11, 21, and 31) separated by 1 cm are indicated. C: Axial MR image demonstrating Slice 1, which is located 20 mm above the AC—PC plane. The arrow indicates the proximal portion of the electrode. D: Axial MR image revealing Slice 11 located 10 mm above the AC—PC plane, with an arrow indicating the proximal portion of the electrode. E: Axial MR image exhibiting Slice 21 located at the AC—PC level, with an arrow indicating the upper part of the terminal portion of the contacts. F: Axial MR image demonstrating Slice 31 located 10 mm below the AC—PC level, with an arrow indicating the lowest contact of the electrode. Note that the proximal portion of the electrode is thinner than the terminal contacts.

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    A: The atlas section PC −3.5 superimposed onto a reformatted MR image of the corresponding section in a patient. Both images are at the same magnification, but the atlas contours do not fit the MR image. B: The figure from the atlas has been enlarged along the mediolateral and anteroposterior axes so that the landmarks coincide: AC, medial border of the putamen (Pu), anterior column of the fornix (Fx), and mamillothalamic tract (MTT). Note that the artifact of the contact now appears within the STN.

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    Images demonstrating the localization of 20 therapeutic contacts determined using 3D atlas—MR imaging coregistration in each of 10 patients. Each contact is identified by the patient number (from 0 to 9). The mediolateral and rostrocaudal dimensions are indicated by the two centimetric orthogonal axes, the origin of which corresponds to the PC point. The dorsoventral dimension is given for each level by its position with reference to the PC plane.

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    Images demonstrating localization of 20 distant contacts determined using 3D atlas—MR imaging registration in each of 10 patients. Same presentation as in Fig. 4.

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    Diagram showing the localization of the 40 contacts tested (either therapeutic or distant) and the clinical effect of their stimulation on akinesia. Each square corresponds to a contact identified in the patient (Cases 0–9), the right (R) or left (L) side, and the number of the contact (0–3). Therapeutic contacts are indicated by bold underlining. Squares are placed according to their actual dorsoventral position, from dorsal level PC −1 to ventral level PC −9.5. They are arranged approximately from left to right according to their medial or lateral position. The contacts localized in a given region are grouped together. The clinical effect on akinesia, ranging from −50% improvement (that is, worsening) to 100% improvement, is indicated by a colored scale. MRF = midbrain reticular formation.

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    Diagram showing the localization of the 40 contacts tested (either therapeutic or distant) and the clinical effect of their stimulation on rigidity. Same presentation as in Fig. 6.

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