Avoiding the ventricle: a simple step to improve accuracy of anatomical targeting during deep brain stimulation

Clinical article

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Object

The authors examined the accuracy of anatomical targeting during electrode implantation for deep brain stimulation in functional neurosurgical procedures. Special attention was focused on the impact that ventricular involvement of the electrode trajectory had on targeting accuracy.

Methods

The targeting error during electrode placement was assessed in 162 electrodes implanted in 109 patients at 2 centers. The targeting error was calculated as the shortest distance from the intended stereotactic coordinates to the final electrode trajectory as defined on postoperative stereotactic imaging. The trajectory of these electrodes in relation to the lateral ventricles was also analyzed on postoperative images.

Results

The trajectory of 68 electrodes involved the ventricle. The targeting error for all electrodes was calculated: the mean ± SD and the 95% CI of the mean was 1.5 ± 1.0 and 0.1 mm, respectively. The same calculations for targeting error for electrode trajectories that did not involve the ventricle were 1.2 ± 0.7 and 0.1 mm. A significantly larger targeting error was seen in trajectories that involved the ventricle (1.9 ± 1.1 and 0.3 mm; p < 0.001). Thirty electrodes (19%) required multiple passes before final electrode implantation on the basis of physiological and/or clinical observations. There was a significant association between an increased requirement for multiple brain passes and ventricular involvement in the trajectory (p < 0.01).

Conclusions

Planning an electrode trajectory that avoids the ventricles is a simple precaution that significantly improves the accuracy of anatomical targeting during electrode placement for deep brain stimulation. Avoidance of the ventricles appears to reduce the need for multiple passes through the brain to reach the desired target as defined by clinical and physiological observations.

Abbreviation used in this paper:DBS = deep brain stimulation.

Article Information

Address correspondence to: Ludvic Zrinzo, M.D., Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology & National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom. email: l.zrinzo@ion.ucl.ac.uk.

Please include this information when citing this paper: published online March 20, 2009; DOI: 10.3171/2008.12.JNS08885.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Upper: Postimplantation stereotactic MR image showing the trajectory view along the implanted DBS lead. The distal portion of the electrode generates a cylindrical hyposignal with a more bulbous terminal portion. The trajectory of the implanted DBS lead can be established in stereotactic space as can the stereotactic coordinates of the electrode contacts. These coordinates can be transposed to the preoperative stereotactic MR images to provide precise localization of the contacts in relation to the visualized anatomy. Lower: The targeting error (d) is defined as the shortest distance between the final target and the electrode trajectory and is represented by a perpendicular line dropped from the intended target (gray cross) to the electrode trajectory (T). Given the coordinates of the final target and of the distal and proximal electrode contacts, the targeting error (d) can be calculated geometrically using Heron's formula. Inset: The vector components (x, y, and z) of the targeting error are shown.

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    A: Axial stereotactic T1-weighted MR images obtained in a patient at the Los Angeles center. Hypointense DBS lead artifacts (arrowheads) are shown. The left DBS lead can be seen within the left frontal horn (upper) indicative of ventricular involvement before reentering parenchyma further along the trajectory (lower). The DBS lead artifact in the right hemisphere is clearly seen embedded within brain parenchyma. B: Coronal T1-weighted MR image (nonstereotactic) obtained in a patient at the Groningen center. The DBS lead artifact can be seen to traverse the lateral ventricle in the left hemisphere and is clearly embedded within brain parenchyma throughout its trajectory in the right hemisphere.

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    Box-and-whisker graph showing combined data from both centers in the study. The 95% CI of the mean (box) and the SD (whiskers) of the targeting error is shown for all electrode trajectories and for Groups 1 and 2. There is a significantly larger targeting error for trajectories involving the ventricle (Group 2) compared with those solely traversing brain parenchyma (Group 1; p < 0.001).

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    Bar graph showing the percentage distribution of targeting error in the 2 groups of electrode trajectories. Note that 86% of electrode trajectories in Group 1 had targeting errors < 2.0 mm compared with 63% of electrodes in Group 2. Also, in contrast to Group 2, no electrodes from Group 1 had a targeting error of > 4.0 mm.

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