Cortical and subcortical brain shift during stereotactic procedures

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Object

The success of stereotactic surgery depends upon accuracy. Tissue deformation, or brain shift, can result in clinically significant errors. The authors measured cortical and subcortical brain shift during stereotactic surgery and assessed several variables that may affect it.

Methods

Preoperative and postoperative magnetic resonance imaging volumes were fused and 3D vectors of deviation were calculated for the anterior commissure (AC), posterior commissure (PC), and frontal cortex. Potential preoperative (age, diagnosis, and ventricular volume), intraoperative (stereotactic target, penetration of ventricles, and duration of surgery), and postoperative (volume of pneumocephalus) variables were analyzed and correlated with cortical (frontal cortex) and subcortical (AC, PC) deviations.

Results

Of 66 cases, nine showed a shift of the AC by more than 1.5 mm, and five by more than 2.0 mm. The largest AC shift was 5.67 mm. Deviation in the x, y, and z dimensions for each case was determined, and most of the cortical and subcortical shift occurred in the posterior direction. The mean 3D vector deviations for frontal cortex, AC, and PC were 3.5 ± 2.0, 1.0 ± 0.8, and 0.7 ± 0.5 mm, respectively. The mean change in AC–PC length was −0.2 ± −0.9 mm (range −4.28 to 1.66 mm). The volume of postoperative pneumocephalus, assumed to represent cerebrospinal fluid (CSF) loss, was significantly correlated with shift of the frontal cortex (r = 0.640, 64 degrees of freedom, p < 0.001) and even more strongly with shift of the AC (r = 0.754, p < 0.001). No other factors were significantly correlated with AC shift. Interestingly, penetration of the ventricles during electrode insertion, whether unilateral or bilateral, did not affect volume of pneumocephalus.

Conclusions

Cortical and subcortical brain shift occurs during stereotactic surgery as a direct function of the volume of pneumocephalus, which probably reflects the volume of CSF that is lost. Clinically significant shifts appear to be uncommon, but stereotactic surgeons should be vigilant in preventing CSF loss.

Abbreviations used in this paper:AC = anterior commissure; CSF = cerebrospinal fluid; DBS = deep brain stimulation; df = degrees of freedom; GPI = globus pallidus internus; MER = microelectrode recording; MPRAGE = magnetization-prepared rapid acquisition gradient echo; MR = magnetic resonance; PC = posterior commissure; SD = standard deviation; STN = subthalamic nucleus; TSE = turbo spin echo; VIM = ventral intermediate nucleus of the thalamus.

Abstract

Object

The success of stereotactic surgery depends upon accuracy. Tissue deformation, or brain shift, can result in clinically significant errors. The authors measured cortical and subcortical brain shift during stereotactic surgery and assessed several variables that may affect it.

Methods

Preoperative and postoperative magnetic resonance imaging volumes were fused and 3D vectors of deviation were calculated for the anterior commissure (AC), posterior commissure (PC), and frontal cortex. Potential preoperative (age, diagnosis, and ventricular volume), intraoperative (stereotactic target, penetration of ventricles, and duration of surgery), and postoperative (volume of pneumocephalus) variables were analyzed and correlated with cortical (frontal cortex) and subcortical (AC, PC) deviations.

Results

Of 66 cases, nine showed a shift of the AC by more than 1.5 mm, and five by more than 2.0 mm. The largest AC shift was 5.67 mm. Deviation in the x, y, and z dimensions for each case was determined, and most of the cortical and subcortical shift occurred in the posterior direction. The mean 3D vector deviations for frontal cortex, AC, and PC were 3.5 ± 2.0, 1.0 ± 0.8, and 0.7 ± 0.5 mm, respectively. The mean change in AC–PC length was −0.2 ± −0.9 mm (range −4.28 to 1.66 mm). The volume of postoperative pneumocephalus, assumed to represent cerebrospinal fluid (CSF) loss, was significantly correlated with shift of the frontal cortex (r = 0.640, 64 degrees of freedom, p < 0.001) and even more strongly with shift of the AC (r = 0.754, p < 0.001). No other factors were significantly correlated with AC shift. Interestingly, penetration of the ventricles during electrode insertion, whether unilateral or bilateral, did not affect volume of pneumocephalus.

Conclusions

Cortical and subcortical brain shift occurs during stereotactic surgery as a direct function of the volume of pneumocephalus, which probably reflects the volume of CSF that is lost. Clinically significant shifts appear to be uncommon, but stereotactic surgeons should be vigilant in preventing CSF loss.

With well-recognized benefits and outcomes, functional neurosurgical procedures like DBS have increased dramatically in popularity and are commonly used to treat medically refractory movement disorders like Parkinson disease, tremor, and dystonia. Possible extension of this technology to nonmovement disorders such as epilepsy or neuropsychiatric conditions will increase the number of stereotactic procedures performed.1,9,13,15,16 Surgical intervention utilizing infusion technologies or gene therapy will also depend upon the same stereotactic precision of delivery.11 Regardless of the disease treated, treatment success depends upon accuracy. Several articles have explored sources of error in stereotactic surgery that result from distortion of the imaging used for targeting or from mechanical issues involving the frame system.2–5,7,18,19,21–24 In this article, we focus on another potential source of error, tissue deformation during stereotactic surgery.

Tissue deformation during brain surgery, or brain shift, can result from brain retraction, cerebral edema, excision of tissue, or loss of CSF. Clinically significant brain shift has been repeatedly demonstrated in craniotomy procedures. Kelly and colleagues8 were probably the first to demonstrate brain shift during stereotactic craniotomy for tumor resection, and similar findings have been validated using in vivo animal studies.12 Substantial brain shifts occur during craniotomy for tumor resection. Roberts and coauthors17 quantified intraoperative cortical shift and demonstrated displacements of the cerebral cortex averaging 1 cm in the direction associated with gravity, and these deviations seemed independent of the craniotomy size or orientation. Nimsky and associates14 used low-field intraoperative MR imaging to similarly evaluate brain deformation during craniotomy and identified large variabilities in the amount of brain shift that occurs. In 63% of their cases cortical shifts of 7 mm or greater developed, and 66% of the cases were associated with displacements of deep tumor margins of 3 mm or greater.14 Like Roberts et al., Nimsky and colleagues found no strong correlation between the size of the craniotomy and the amount of shift. Both groups of authors, however, suggest the use of intraoperative imaging with ultrasound or MR imaging to accommodate for subsurface shifting,14,17 and Soza et al.20 have proposed a computer model of brain shift to aid real-time image-guided interventions.

The magnitude of brain shift observed in craniotomy procedures raises the question of the clinical significance of the phenomenon in less-invasive brain surgery. There have been studies dealing with brain shift as at least one factor affecting the overall accuracy of electrode placement during functional and stereotactic surgeries.3–5,7,18,21 A single case study documented clinically significant brain shift during DBS surgery.25 There is, however, little information concerning the incidence of clinically significant brain shift in stereotactic procedures or risk factors that may be predictive of it. In this project, we examined our series of DBS cases and quantified differences between pre- and postoperative MR images to identify the degree of brain shift that occurred in the cortex, AC, and PC. We then looked for correlations between brain shift and several potential risk factors from the preoperative condition, the surgical procedure, and postoperative variables.

Clinical Material and Methods

Patient Population

We retrospectively reviewed our cases in which frame-based stereotactic procedures were performed for the treatment of movement disorders between 2004 and 2006. Patients with movement disorders who were treated with DBS for Parkinson disease, tremor, or dystonia were included in the series. Patients were excluded if there was no pre- or postoperative MR imaging study for analysis, or if image quality was degraded by movement artifact. Sixty-six patients were included in the analysis (Table 1).

TABLE 1

Clinical and demographic characteristics of 66 patients who underwent frame-based sterotactic DBS surgery*

VariableValue
male sex (%)74
mean age (yrs)59.5
mean ventricular vol (cm3)27.5
diagnosis (no. of patients [%])
 PD41 (62)
 essential tremor15 (23)
 dystonia10 (15)
no. of DBS ops71
DBS target (no. of patients [%])
 STN33 (50)
 GPI18 (27)
 VIM15 (23)
bilateral procedures (%)58
MER in patients w/ PD (no. of cases)33
ventricular puncture by electrode (% of ops)50
mean duration of op3 hrs 42 mins

* PD = Parkinson disease.

Stereotactic Surgical Procedures

All stereotactic surgical procedures were performed with the Leksell model G stereotactic frame and arc. Frame placement was performed the morning of surgery, and the preoperative MR imaging study was obtained immediately following frame placement. General anesthesia was used for frame placement, MR image acquisition, and surgical electrode placement in 10 patients with severe dystonia. In most movement disorder cases, the procedures were performed without sedation to permit intraoperative stimulation testing. Microelectrode recording was conducted in patients with Parkinson disease who were treated with STN DBS.

For our stereotactic procedures, we insert electrodes through 14-mm-diameter precoronal bur holes. A Navigus intracranial cap (Image-Guided Neurologics) was used to secure the DBS electrodes. During electrode insertion or MER, patients are maintained in a semirecumbent position to minimize CSF loss, and the bur holes were occluded with Gelfoam. We have not used tissue sealants or cranioplasty cement. Final electrode position was confirmed intraoperatively with lateral skull fluoroscopy and then postoperatively with MR imaging the following day.

Surgical and Neuroimaging Time

Duration of surgery was recorded by the nursing staff for each case and is defined as the time from incision to closure. Postoperative MR imaging latency was defined as the interval from the time of closure until the beginning of the postoperative MR imaging study.

Magnetic Resonance Imaging

Images were acquired on a 1.5-tesla MR imaging unit (Siemens Magnetom Vision Plus, Siemens Medical Systems) following Leksell frame placement. Patients were positioned supine for all MR image acquisitions. Volumetric 3D MPRAGE sequences with a 210-mm-thick volume at 1.4-mm slices were obtained initially as follows: field of view 250 mm, 192 ×256 matrix, TR 9.7 msec, TE 4 msec, and pulse flip angle of 10°. Next a 2D TSE sequence was acquired at 2-mm slices with no intervening gap as follows: field of view 250 mm, 224 × 256 matrix, TR 4575 msec, TE 96 msec, and a pulse flip angle of 180°.

The images were transferred via network to the Stealth neuronavigation station (Medtronic) in the operating room, where Framelink 4.0 software (Medtronic) was used to plan the surgical target and trajectory. Following image fusion of the MPRAGE and TSE sequences, direct targeting on TSE images was used for identification of the STN.

Postoperative MR images with the same sequences were obtained the day following surgery to localize final electrode position. These data sets were transferred over a network into the Stealth workstation, and the electrode position was verified on 3D reconstructions. Electrode trajectories were followed to determine penetration of right or left ventricle, both ventricles, or neither ventricle.

The preoperative volumes of lateral and third ventricles were estimated using MRIcro software (freely available at http://www.sph.sc.edu/comd/rorden/mricro.html) applied to MPRAGE images. Voxel intensity thresholding was used to distinguish CSF volumes within a sphere enclosing the lateral and third ventricles and excluding the rim of the cortical mantle. Postoperative pneumocephalus estimates were measured on the postoperative MPRAGE sequence by resetting the threshold to select for the voxel density of air. Volumes were converted from voxels to cubic centimeters for analysis.

Brain shift was determined on the Stealth workstation. Preoperative and postoperative MPRAGE MR image volumes were carefully fused using osseous cranial landmarks as reference points. The x, y, and z coordinates were obtained for the AC, PC, and frontal pole on pre- and postoperative MR images. The right or left frontal pole was chosen based on the side showing the largest volume of pneumocephalus. If air was not apparent on the postoperative images, we chose the side that projected most anteriorly. Mean shift between identical anatomical points in the pre- and postoperative images was calculated in the lateral (x), anterior–posterior (y), and vertical (z) dimensions. The actual distance of brain shift for any point was defined as the 3D vector of deviation, which was calculated for each of the three points in each patient.

Statistical Analysis

We examined a series of preoperative, intraoperative, and postoperative variables that may contribute to brain deformation (Table 2). The relationship between ratio scale factors and brain shift was assessed with linear regression and the Pearson r statistic. The effect of nominal factors was evaluated by sorting patients into groups (for example, by diagnosis) and testing differences in mean brain shift with a univariate analysis of variance (general linear model, SPSS). Mean values are presented ± SDs.

TABLE 2

Variables assessed for brain shift

preoperative
 age (yrs)
 diagnosis
 ventricular vol (cm3) ~ cerebral atrophy
intraoperative
 stereotactic target (STN, GPI, VIM)
 duration of surgery (mins)
 ventricular penetration by electrode
postoperative
 vol of pneumocephalus (cm3) ~ CSF loss

Results

Patient Demographics

Sixty-six patients who underwent 71 stereotactic DBS procedures and had pre- and postoperative high-resolution MR imaging for analysis were included in the study. Seventy-four percent of the patients were male, and the mean age for the entire cohort was 59 years 5 months ± 15 years 10 months (range 5 years 7 months–85 years 3 months). Most of the patients had Parkinson disease (41 patients), but there were also patients with essential tremor (15 patients) and dystonia (10 patients). The mean volume of the patients' lateral and third ventricles was 27.48 ±24.50 cm3 (range 1.60–128.22 cm3, Table 1).

Surgical Data

Electrodes were stereotactically inserted into the following subcortical targets: the VIM (15 patients), STN (33 patients), and GPI (18 patients). Fifty-eight percent of the cases were bilateral. Microelectrode recording was performed during all 33 STN DBS procedures. The mean surgical time was 3 hours 42 minutes ± 1 hour 13 minutes (Table 1), and the mean time between wound closure and postoperative MR imaging was 32 hours 1 minute. The frontal horn of the lateral ventricle was traversed bilaterally in 23% of cases, unilaterally in 33%, and not at all in 44%. Pneumocephalus was observed on the postoperative MR images in 40 cases and the mean volume of air (for all cases) was 4.3 ± 8.05 cm3. Preoperative, intraoperative, and postoperative variables were analyzed for each case (Table 2).

Brain Shift

Magnetic resonance imaging studies were performed with the patient in the supine position, and brain shift was greatest in the more anterior structures. In most cases, the observed shift was small. The mean lateral (x), antero-posterior (y), and vertical (z) shifts for the AC were 0.04, 0.56, and 0.14 mm, respectively, across all patients. Greater shifts for the frontal cortex were noted with mean values of 0.09, 2.66, and –0.08 mm, respectively. The mean 3D vector deviations for frontal cortex, AC, and PC were 3.51 ± 2.02, 0.98 ± 0.80, and 0.74 ± 0.48 mm, respectively. The principal direction of deviation for superficial and deep structures in these supine patients was posterior along the y axis (Table 3).

TABLE 3

Cortical and subcortical deviations (in millimeters) following DBS surgery*

Coordinate
ParameterxyzLength3D Vector
frontal pole
 mean0.092.66−0.08NA3.51
 SD1.442.101.70NA2.02
 min−4.10−0.56−4.49NA0.62
 max3.5210.425.53NA10.91
AC
 mean0.040.560.14NA0.98
 SD0.380.900.57NA0.80
 min−0.89−0.97−1.47NA0.21
 max1.955.591.68NA5.67
PC
 mean0.080.33−0.11NA0.74
 SD0.450.450.51NA0.48
 min−0.89−0.50−1.63NA0.03
 max2.341.700.97NA2.75
AC–PC
 meanNANANA−0.22NA
 SDNANANA0.85NA
 minNANANA1.66NA
 maxNANANA−4.28NA

* Values represent differences between pre- and postoperative measurements. Abbreviation: NA = not applicable.

Some subcortical shifts were large enough to be clinically significant. In nine cases we found that the AC had shifted by more than 1.5 mm; in five cases, more than 2.0 mm. The largest AC shift was 5.67 mm, which could introduce a significant error in placement. The mean difference in AC–PC length postoperatively was −0.22 ±−0.85 mm (range −4.28 to 1.66 mm).

Statistical Analysis

Volume of postoperative pneumocephalus, probably reflecting the volume of CSF loss, was the only factor significantly associated with brain deformation. Volume of pneumocephalus was significantly correlated with shift of the frontal cortex (r = 0.640, 64 df, p < 0.001; Fig. 1) and was even more significantly associated with brain deformation at the deeper level of the AC (r = 0.754, 64 df, p < 0.001; Fig. 2).

Fig. 1.
Fig. 1.

Graph demonstrating the correlation between the volume of postoperative pneumocephalus and the vector deviation of the frontal cortex in millimeters (r = 0.640, 64 df).

Fig. 2.
Fig. 2.

Graph demonstrating the correlation between the volume of postoperative pneumocephalus and the deviation of the AC in millimeters (r = 0.754, 64 df).

There was no significant association between AC shift and age (r = 0.055, 64 df), preoperative ventricular volume (r = 0.096, 64 df), or duration of surgery (r = 0.094, 64 df). Extent of AC shift did not differ across diagnoses (F = 2.178; 2, 63 df; p = 0.122) or in relationship to trajectories penetrating or missing the ventricles (F = 1.873; 3, 63 df; p = 0.143).

Pneumocephalus is clearly important, but it does not correlate with other factors we examined. Factors that were not significantly associated with the volume of pneumocephalus include the following: latency to postoperative imaging (r = 0.180, 64 df), duration of surgery (r = 0.133, 64 df), age (r = 0.109, 64 df), and preoperative ventricular volume (r = 0.056, 64 df). Mean volumes of pneumocephalus did not differ across stereotactic targets (STN, GPI, or VIM; F = 1.046; 2, 63 df; p = 0.357) or diagnoses (F = 1.042; 2, 63 df; p = 0.359). There was no significant difference in volume of pneumocephalus with respect to ventricle penetration during surgery—that is, depending on whether the trajectories penetrated both ventricles, the right ventricle, the left ventricle, or neither lateral ventricle (F = 1.471; 3, 62 df; p = 0.231).

Discussion

This study demonstrates that clinically significant shifts in subcortical structures can occur in association with CSF loss. The regression formula for our series suggests that a loss of 20 cm3 of CSF is roughly associated with a shift in the AC of about 2 mm. We found little significant brain shift in the majority of cases in our series, irrespective of age, ventricular volume, diagnosis, surgery duration, or penetration of lateral ventricles. The mean deviation of the frontal cortex postoperatively was 3.51 ± 2.02 mm, while that for the AC was 0.98 ± 0.80 mm. The principal direction of shift for cortical and subcortical structures was posteriorly along the y axis (Table 3).

Volume of pneumocephalus was the only predictive factor for cortical and subcortical brain shift (r = 0.640 and 0.754, respectively). We assume that the volume of postoperative pneumocephalus approximates the volume of CSF that is lost during the surgical procedure because cerebral tissue volume is essentially constant throughout DBS surgery. Tension pneumocephalus, a condition whereby intracranial air may not equal CSF lost, is not observed in DBS procedures. While the correlation between pneumocephalus and brain shift may not be surprising, the prediction or anticipation of clinically significant CSF loss during stereotactic surgery proved difficult. We assumed that large ventricular volume and cerebral atrophy would enhance the risk of CSF loss and brain shift; we found no significant association between the development of hydrocephalus and patient age, disease, or baseline ventricular volume. Preoperative ventricular volume was evaluated as an estimate of the degree of cerebral atrophy that may have been present.

Similarly, we assumed that longer duration of surgery and electrode trajectories penetrating the ventricles would lead to increased pneumocephalus. With open cranial surgery, Nimsky et al.14 found that ventricular opening did lead to increased amounts of cortical shift, albeit with little effect on deeper tumor margins. In our series, however, duration of the operation did not correlate with air volume, and penetration of the ventricular system with electrode insertion, whether unilateral or bilateral, did not seem to result in either increased air or shift of the deeper brain structures.

Our study was not focused toward defining the direction of intraoperative brain shift. The major direction of shift occurred posteriorly along the y axis in our image sets, presumably because of gravity. Magnetic resonance image acquisition occurs with the patient in the supine position, whereas DBS surgery is performed with the patient in a semirecumbent position. It has been shown that very little shift, perhaps less than 1 mm, occurs during patient positioning in the absence of pneumocephalus.6,14 In our estimation, brain shift is a 3D phenomenon subject to the forces of gravity on brain position.17

In this retrospective review, we were unable to identify preoperative variables that could distinguish patients at the highest risk for CSF loss and thus brain shift—perhaps because we make every possible effort to minimize CSF loss during DBS surgery at our institution (Fig. 3). We place the patient in a semirecumbent position with the head maintained upright, and bur holes are occluded with Gelfoam once the electrodes are inserted. This protocol may reduce the risk of CSF loss such that even vulnerable cases show little brain shift. The average 32-hour lag between the operation and the postoperative scan may have allowed some recovery of CSF volume in patients with pneumocephalus. However, in five (7.6%) of 66 cases there was a shift in the AC of 2 mm or more. Based on the results of this study, we are considering revising our procedure to further reduce CSF loss with tissue sealants. Our patients typically receive intranasal oxygen during surgery and briefly during the postoperative period, but we were unable to quantify its use or determine its effect on the development of pneumocephalus.

Fig. 3.
Fig. 3.

Comparison of fused pre- and postoperative axial MR images demonstrating brain shift. Arrows in panels A and B indicate preoperative positions of AC (upper arrow) and PC (lower arrow). A: Preoperative image at AC–PC line. B: Postoperative image with posterior shift of AC. C: Preoperative image through lateral ventricles. D: Postoperative image showing pneumocephalus and serpentine septum, a neuroimaging sign of ventricular decompression and CSF loss.

Accurate assessment of CSF loss (and hence the risk of brain shift) can be difficult during a stereotactic procedure. The demonstration of clinically significant brain shift associated with DBS operations supports the use of intraoperative electrophysiological confirmation of subcortical stereotactic targets with MER or test stimulation.3,10 The results of future studies using intraoperative MR imaging may better elucidate mechanisms in the development of brain shift or the timing of its occurrence during stereotactic procedures.

Conclusions

The results of this study demonstrate that a clinically significant shift of cortical and deep subcortical structures occurs during stereotactic surgery as a relatively linear function of intracerebral air, which probably reflects CSF loss. Because of the minimal invasiveness of stereotactic surgery and the findings of this study, we suggest that brain deformation during stereotactic surgery results primarily from CSF changes and not tissue retraction, extraction, or edema.

Acknowledgment

The authors thank Cindy Roberson for her assistance with manuscript preparation.

References

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    Abelson JLCurtis GCSagher OAlbucher RCHarrigan MTaylor SF: Deep brain stimulation for refractory obsessive-compulsive disorder. Biol Psychiatry 57:5105162005

  • 2

    Burchiel KJNguyen TTCoombs BDSzumoski J: MRI distortion and stereotactic neurosurgery using the Cosman-Roberts-Wells and Leksell frames. Stereotact Funct Neurosurg 66:1231361996

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    Cuny EGuehl DBurbaud PGross CDousset VRougier A: Lack of agreement between direct magnetic resonance imaging and statistical determination of a subthalamic target: the role of electrophysiological guidance. J Neurosurg 97:5915972002

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    Fitzpatrick JMKonrad PENickele CCetinkaya EKao C: Accuracy of customized miniature stereotactic platforms. Stereotact Funct Neurosurg 3:25312005

  • 5

    Hamid NAMitchell RDMocroft PWestby GWMilner JPall H: Targeting the subthalamic nucleus for deep brain stimulation: technical approach and fusion of pre- and postoperative MR images to define accuracy of lead placement. J Neurol Neurosurg Psychiatry 76:4094142005

  • 6

    Hill DLMaurer CR JrMaciunas RJBarwise JAFitzpatrick JMWang MY: Measurement of intraoperative brain surface deformation under a craniotomy. Neurosurgery 43:5145281998

  • 7

    Holloway KLGaede SEStarr PARosenow JMRamakrishman VHenderson JM: Frameless stereotaxy using bone fiducial markers for deep brain stimulation. J Neurosurg 103:4044132005

  • 8

    Kelly PJKall BAGoerss SEarnest F: Computer-assisted stereotaxic laser resection of intra-axial brain neoplasms. J Neurosurg 64:4274391986

  • 9

    Kerrigan JFLitt BFisher RSCranstoun SFrench JABlum DE: Electrical stimulation of the anterior nucleus of the thalamus for the treatment of intractable epilepsy. Epilepsia 45:3463542004

  • 10

    Kirschman DLMilligan BWilkinson SOverman JWetzel LBatnitzky S: Pallidotomy microelectrode targeting: neurophysiology-based target refinement. Neurosurgery 46:6136242000

  • 11

    Lang AEGill SPatel NKLozano ANutt JGPenn R: Randomized controlled trial of intraputamenal glial cell line-derived neurotrophic factor infusion in Parkinson disease. Ann Neurol 59:4594662006

  • 12

    Lunn KEPaulsen KDRoberts DWKennedy FEHartov AWest JD: Displacement estimation with co-registered ultrasound for image guided neurosurgery: a quantitative in vivo porcine study. IEEE Trans Med Imaging 22:135813682003

  • 13

    Mayberg HSLozano AMVoon VMcNeely HESeminowicz DHamani C: Deep brain stimulation for treatment-resistant depression. Neuron 45:6516602003

  • 14

    Nimsky CGanslandt OCerny SHastreiter PGreiner GFahlbusch R: Quantification of, visualization of, and compensation for brain shift using intraoperative magnetic resonance imaging. Neurosurgery 47:107010802000

  • 15

    Nuttin BJGabriels Lvan Kuyck KCosyns P: Electrical stimulation of the anterior limbs of the internal capsules in patients with severe obsessive-compulsive disorder: anecdotal reports. Neurosurg Clin N Am 14:2672742003

  • 16

    Nuttin BJGabriels LACosyns PRMeyerson BAAndreewitch SSunaert SG: Long-term electrical capsular stimulation in patients with obsessive-compulsive disorder. Neurosurgery 52:126312722003

  • 17

    Roberts DWHartov AKennedy FEMiga MIPaulsen KD: Intraoperative brain shift and deformation: a quantitative analysis of cortical displacement in 28 cases. Neurosurgery 43:7497601998

  • 18

    Schrader BHamel WWeinert DMehdorn HM: Documentation of electrode localization. Mov Disord 17:3 SupplS167S1742002

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    Slavin KVAnderson GJBurchiel KJ: Comparison of three techniques for calculation of target coordinates in functional stereotactic procedures. Stereotact Funct Neurosurg 72:1921951999

  • 20

    Soza GGrosso RLabsik UNimsky CFahlbusch RGreiner G: Fast and adaptive finite element approach for modeling brain shift. Comput Aided Surg 8:2412462003

  • 21

    Starr PAChristine CWTheodosopoulos PVLindsey NByrd DMosley A: Implantation of deep brain stimulators into the subthalamic nucleus: technical approach and magnetic resonance imaging-verified lead locations. J Neurosurg 97:3703872002

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

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    Sumanaweera TSGlover GHHemler PFvan den Elsen PAMartin DAdler JR: MR geometric distortion correction for improved frame-based stereotaxic target localization accuracy. Magn Reson Med 34:1061131995

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

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    Winkler DTittgemeyer MSchwarz JPruel CStrecker KMeixensberger J: The first evaluation of brain shift during functional neurosurgery by deformation field analysis. J Neurol Neurosurg Psychiatry 76:116111632005

This work was presented at the American Society of Stereotactic and Functional Neurosurgeons in Boston, Massachusetts, on June 3, 2006.

Article Information

Address correspondence to: W. Jeffrey Elias, M.D., Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, Virginia 22908. email: wje4r@virginia.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graph demonstrating the correlation between the volume of postoperative pneumocephalus and the vector deviation of the frontal cortex in millimeters (r = 0.640, 64 df).

  • View in gallery

    Graph demonstrating the correlation between the volume of postoperative pneumocephalus and the deviation of the AC in millimeters (r = 0.754, 64 df).

  • View in gallery

    Comparison of fused pre- and postoperative axial MR images demonstrating brain shift. Arrows in panels A and B indicate preoperative positions of AC (upper arrow) and PC (lower arrow). A: Preoperative image at AC–PC line. B: Postoperative image with posterior shift of AC. C: Preoperative image through lateral ventricles. D: Postoperative image showing pneumocephalus and serpentine septum, a neuroimaging sign of ventricular decompression and CSF loss.

References

1

Abelson JLCurtis GCSagher OAlbucher RCHarrigan MTaylor SF: Deep brain stimulation for refractory obsessive-compulsive disorder. Biol Psychiatry 57:5105162005

2

Burchiel KJNguyen TTCoombs BDSzumoski J: MRI distortion and stereotactic neurosurgery using the Cosman-Roberts-Wells and Leksell frames. Stereotact Funct Neurosurg 66:1231361996

3

Cuny EGuehl DBurbaud PGross CDousset VRougier A: Lack of agreement between direct magnetic resonance imaging and statistical determination of a subthalamic target: the role of electrophysiological guidance. J Neurosurg 97:5915972002

4

Fitzpatrick JMKonrad PENickele CCetinkaya EKao C: Accuracy of customized miniature stereotactic platforms. Stereotact Funct Neurosurg 3:25312005

5

Hamid NAMitchell RDMocroft PWestby GWMilner JPall H: Targeting the subthalamic nucleus for deep brain stimulation: technical approach and fusion of pre- and postoperative MR images to define accuracy of lead placement. J Neurol Neurosurg Psychiatry 76:4094142005

6

Hill DLMaurer CR JrMaciunas RJBarwise JAFitzpatrick JMWang MY: Measurement of intraoperative brain surface deformation under a craniotomy. Neurosurgery 43:5145281998

7

Holloway KLGaede SEStarr PARosenow JMRamakrishman VHenderson JM: Frameless stereotaxy using bone fiducial markers for deep brain stimulation. J Neurosurg 103:4044132005

8

Kelly PJKall BAGoerss SEarnest F: Computer-assisted stereotaxic laser resection of intra-axial brain neoplasms. J Neurosurg 64:4274391986

9

Kerrigan JFLitt BFisher RSCranstoun SFrench JABlum DE: Electrical stimulation of the anterior nucleus of the thalamus for the treatment of intractable epilepsy. Epilepsia 45:3463542004

10

Kirschman DLMilligan BWilkinson SOverman JWetzel LBatnitzky S: Pallidotomy microelectrode targeting: neurophysiology-based target refinement. Neurosurgery 46:6136242000

11

Lang AEGill SPatel NKLozano ANutt JGPenn R: Randomized controlled trial of intraputamenal glial cell line-derived neurotrophic factor infusion in Parkinson disease. Ann Neurol 59:4594662006

12

Lunn KEPaulsen KDRoberts DWKennedy FEHartov AWest JD: Displacement estimation with co-registered ultrasound for image guided neurosurgery: a quantitative in vivo porcine study. IEEE Trans Med Imaging 22:135813682003

13

Mayberg HSLozano AMVoon VMcNeely HESeminowicz DHamani C: Deep brain stimulation for treatment-resistant depression. Neuron 45:6516602003

14

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