DBS targeting for essential tremor using intersectional dentato-rubro-thalamic tractography and direct proton density visualization of the VIM: technical note on 2 cases

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  • 1 Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco;
  • | 2 Department of Radiology & Biomedical Imaging, University of California, San Francisco; and
  • | 3 Department of Neurology, Movement Disorders and Neuromodulation Center, Weill Institute for Neurosciences, University of California, San Francisco, California
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OBJECTIVE

Direct visualization of the ventral intermediate nucleus (VIM) of the thalamus on standard MRI sequences remains elusive. Therefore, deep brain stimulation (DBS) surgery for essential tremor (ET) indirectly targets the VIM using atlas-derived consensus coordinates and requires awake intraoperative testing to confirm clinical benefits. The objective of this study was to evaluate the utility of proton density (PD)–weighted MRI and tractography of the intersecting dentato-rubro-thalamic tract (DRTT) for direct “intersectional” targeting of the VIM in ET.

METHODS

DBS targets were selected by identifying the VIM on PD-weighted images relative to the DRTT in 2 patients with ET. Tremor reduction was confirmed with intraoperative clinical testing. Intended target coordinates based on the direct intersectional targeting technique were compared with consensus coordinates obtained with indirect targeting. Pre- and postoperative tremor scores were assessed using the Fahn-Tolosa-Marin tremor rating scale (TRS).

RESULTS

Planned DBS coordinates based on direct versus indirect targeting of the VIM differed in both the anteroposterior (range 0 to 2.3) and lateral (range −0.7 to 1) directions. For 1 patient, indirect targeting—without PD-weighted visualization of the VIM and DRTT—would have likely resulted in suboptimal electrode placement within the VIM. At the 3-month follow-up, both patients demonstrated significant improvement in tremor symptoms subjectively and according to the TRS (case 1: 68%, case 2: 72%).

CONCLUSIONS

Direct intersectional targeting of the VIM using PD-weighted imaging and DRTT tractography is a feasible method for DBS placement in patients with ET. These advanced targeting techniques can supplement awake intraoperative testing or be used independently in asleep cases to improve surgical efficiency and confidence.

ABBREVIATIONS

AC-PC = anterior commissure–posterior commissure; AP = anteroposterior; DBS = deep brain stimulation; DRTT = dentato-rubro-thalamic tract; DTI = diffusion tensor imaging; ET = essential tremor; MgFUS = MRI-guided focused ultrasound; PD = proton density; TRS = Fahn-Tolosa-Marin tremor rating scale; VIM = ventral intermediate nucleus.

Artist’s illustration of the classic mulberry appearance of a cavernoma. This illustration represents the Seven Cavernomas series by Dr. Michael Lawton, a collection of articles defining the tenets and techniques for the treatment of cavernous malformations, a taxonomy for classifying these lesions, and the nuances of their surgical approaches. Artist: Peter M. Lawrence. Used with permission from Barrow Neurological Institute, Phoenix, Arizona. See the article by Garcia et al. (pp 671–682).

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Contributor Notes

Correspondence Doris D. Wang: Weill Institute for Neurosciences, University of California, San Francisco, CA. doris.wang@ucsf.edu.

M.A.M. and A.T.L. contributed equally to this work.

INCLUDE WHEN CITING Published online January 15, 2021; DOI: 10.3171/2020.8.JNS201378.

Disclosures Dr. Martin is a consultant for UniQure and receives support from ClearPoint Neuro for work outside of this study. Dr. Wang is a consultant for Medtronic and Boston Scientific.

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