Imaging alone versus microelectrode recording–guided targeting of the STN in patients with Parkinson’s disease

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OBJECTIVE

The clinical results of deep brain stimulation (DBS) of the subthalamic nucleus (STN) are highly dependent on accurate targeting and target implantation. Several targeting tactics are in current use, including image-only and/or electrophysiologically guided approaches using microelectrode recordings (MERs). The purpose of the present study was to make an appraisal of imaging only–based versus imaging with the addition of intraoperative MER-guided STN electrode targeting.

METHODS

The authors evaluated 100 consecutive patients undergoing STN DBS. The position of the STN target was estimated from preoperative MR images (direct target) or in relation to the position of the anterior and posterior commissures (indirect target). MERs were obtained for each trajectory. The authors tracked which targets were adjusted intraoperatively as a consequence of MER data. The final placement of 182 total STN electrodes was validated by intraoperative macrostimulation through the implanted DBS electrodes. The authors compared the image-based direct, indirect, MER-guided target adjustments and the final coordinates of the electrodes as seen on postoperative MRI.

RESULTS

In approximately 80% of the trajectories, there was a good correspondence between the imaging-based and the MER-guided localization of the STN target. In approximately 20% of image-based targeting trajectories, however, the electrophysiological data revealed that the trajectory was suboptimal, missing the important anatomical structures to a significant extent. The greatest mismatch was in the superior-inferior axis, but this had little impact because it could be corrected without changing trajectories. Of more concern were mismatches of 2 mm or more in the mediolateral (x) or anteroposterior (y) planes, discrepancies that necessitated a new targeting trajectory to correct for the mis-targeting. The incidence of mis-targetting requiring a second MER trajectory on the first and second sides was similar (18% and 22%).

CONCLUSIONS

According to the present analysis, approximately 80% of electrodes were appropriately targeted using imaging alone. In the other 20%, imaging alone led to suboptimal targeting that could be corrected by a trajectory course correction guided by the acquired MER data. The authors’ results suggest that preoperative imaging is insufficient to obtain optimal results in all patients undergoing STN DBS.

ABBREVIATIONS AC = anterior commissure; DBS = deep brain stimulation; MCP = midcommissural point; MER = microelectrode recording; PC = posterior commissure; PD = Parkinson’s disease; STN = subthalamic nucleus.

Article Information

Correspondence Andres M. Lozano: University of Toronto, Toronto Western Hospital, Toronto, ON, Canada. lozano@uhnresearch.ca.

INCLUDE WHEN CITING Published online August 3, 2018; DOI: 10.3171/2018.2.JNS172186.

Disclosures A.F. is a consultant for Medtronic and Boston Scientific. A.M.L. is a consultant for Medtronic, St. Jude, and Boston Scientific.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial T1-weighted MR image showing the approximate location of the STN outlined in white.

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    Frequency distribution of coordinate differences between direct MRI-planned and final MRI coordinates of 16 moved right-side electrodes. The figure shows the shift distances in millimeters among the 16 right-side electrodes that were adjusted according to MER data. Preoperative direct imaging targeted the upper to midportion of the STN, while postoperative MRI localized the deepest contact of the DBS electrode. Figure is available in color online only.

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    Frequency distribution of coordinate differences between direct MRI-planned and final MRI-determined coordinates of 20 moved left-side DBS electrodes. The figure shows the shift distances in millimeters among the 20 left-side electrodes that were adjusted according to MER data. Preoperative direct imaging targeted the upper to midportion of the STN, while postoperative MRI localized the deepest contact of the DBS electrode. Figure is available in color online only.

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    Axial T1-weighted MR image showing the DBS electrode artifact on the postoperative scan. Note the blooming effect with electrodes having an apparent 4–6 mm in diameter, while their actual diameter is 1.27 mm.

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