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André Olivier, Isabelle M. Germano, Arthur Cukiert and Terry Peters

✓ Frameless stereotactic techniques used in conjunction with three-dimensional images allow accurate planning and performance of a variety of neurosurgical procedures. The authors have used the frameless stereotactic Allegro Viewing Wand system to provide real-time correlation of the operating field and computerized images in 42 neurosurgical operations, including 31 epilepsy procedures. The system consists of an image-processing computer that creates three-dimensional and triplanar images; a mobile computer to display reformatted magnetic resonance images; and a hand-guided, articulated, position-sensing arm with a probe. At the start of the operation, the probe identifies the patient's facial and scalp features and correlates these with the computerized images. The position-sensing arm can then guide the operation and locate anatomical structures and lesions of interest. This system can be used to advantage in performing smaller craniotomies and intraoperatively locating anatomical structures and lesions to be removed. Postoperative magnetic resonance images demonstrate that this technique was accurate to within 3 mm in measuring the anteroposterior resection of fixed structures, such as hippocampus and corpus callosum. Disadvantages include longer preoperative preparation for data analysis and lack of both real-time computer analysis of tissue removal and angiographic data display. Preliminary experience suggests that the viewing wand system's advantages outweigh the disadvantages, and it is most helpful as an adjunctive navigational device in the microsurgical treatment of epilepsy.

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Emma G. Duerden, Kirk W. Finnis, Terry M. Peters and Abbas F. Sadikot

Object

The somatotopic organization of the motor fibers within the posterior limb of the internal capsule (IC) in humans remains unclear. Several electrophysiological atlases created from stimulation during stereotactic neurosurgery have suggested that there is considerable overlap between representations of body parts. Overlap reported in these studies may have been due to linear scaling methods applied to the data that were unable to account for individual anatomical variability. In the current work, the authors attempted to overcome these limitations by using a nonlinear registration technique to better understand the spatial location and extent of the body-part representations in the IC.

Methods

Data were acquired during 30 cases of deep brain neurosurgery in which the IC was electrically stimulated to localize the ventrolateral nucleus for a subsequent thalamotomy or implantation of a thalamic deep brain stimulator. Motor responses from the tongue, face, arm, or leg were evoked in the IC and coded in the patient's native MR imaging space. The tagged MR images were then nonlinearly registered to a high-resolution template MR image. This work resulted in a functional electrophysiological atlas demonstrating the locations of body-part representations in the posterior limb of the IC that takes individual anatomical variability into account. To further understand the spatial location and extent of the motor responses, the electrophysiological data points were transformed into 3D probability maps that describe the likelihood of obtaining motor responses in the posterior limb of the IC.

Results

The analyses suggest a reliable face-anterior, arm-intermediate, and leg-posterior somatotopic organization in the posterior limb of the IC with little overlap between the body-part representations.

Conclusions

This probabilistic atlas of functional responses evoked by stimulating the posterior limb of the IC provides better understanding of the anatomical organization of descending motor fibers, can be used for indirect intraoperative confirmation of the location of the ventrolateral thalamus, and is applicable to clinical and research MR imaging studies requiring information on spatial organization of motor fibers at the thalamic level in the human brain.

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Jeffrey D. Atkinson, D. Louis Collins, Gilles Bertrand, Terry M. Peters, G. Bruce Pike and Abbas F. Sadikot

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).