Clinical outcomes of pallidal deep brain stimulation for dystonia implanted using intraoperative MRI

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OBJECTIVE

Lead placement for deep brain stimulation (DBS) using intraoperative MRI (iMRI) relies solely on real-time intraoperative neuroimaging to guide electrode placement, without microelectrode recording (MER) or electrical stimulation. There is limited information, however, on outcomes after iMRI-guided DBS for dystonia. The authors evaluated clinical outcomes and targeting accuracy in patients with dystonia who underwent lead placement using an iMRI targeting platform.

METHODS

Patients with dystonia undergoing iMRI-guided lead placement in the globus pallidus pars internus (GPi) were identified. Patients with a prior ablative or MER-guided procedure were excluded from clinical outcomes analysis. Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores and Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores were assessed preoperatively and at 6 and 12 months postoperatively. Other measures analyzed include lead accuracy, complications/adverse events, and stimulation parameters.

RESULTS

A total of 60 leads were implanted in 30 patients. Stereotactic lead accuracy in the axial plane was 0.93 ± 0.12 mm from the intended target. Nineteen patients (idiopathic focal, n = 7; idiopathic segmental, n = 5; DYT1, n = 1; tardive, n = 2; other secondary, n = 4) were included in clinical outcomes analysis. The mean improvement in BFMDRS score was 51.9% ± 9.7% at 6 months and 63.4% ± 8.0% at 1 year. TWSTRS scores in patients with predominant cervical dystonia (n = 13) improved by 53.3% ± 10.5% at 6 months and 67.6% ± 9.0% at 1 year. Serious complications occurred in 6 patients (20%), involving 8 of 60 implanted leads (13.3%). The rate of serious complications across all patients undergoing iMRI-guided DBS at the authors’ institution was further reviewed, including an additional 53 patients undergoing GPi-DBS for Parkinson disease. In this expanded cohort, serious complications occurred in 11 patients (13.3%) involving 15 leads (10.1%).

CONCLUSIONS

Intraoperative MRI–guided lead placement in patients with dystonia showed improvement in clinical outcomes comparable to previously reported results using awake MER-guided lead placement. The accuracy of lead placement was high, and the procedure was well tolerated in the majority of patients. However, a number of patients experienced serious adverse events that were attributable to the introduction of a novel technique into a busy neurosurgical practice, and which led to the revision of protocols, product inserts, and on-site training.

ABBREVIATIONS BFMDRS = Burke-Fahn-Marsden Dystonia Rating Scale; CD = cervical dystonia; CI = confidence interval; CP = cerebral palsy; DBS = deep brain stimulation; GPi = globus pallidus pars internus; ICL = intercommissural line; iMRI = intraoperative MRI; IPG = internal pulse generator; MCP = midcommissural point; MER = microelectrode recording; PD = Parkinson disease; QSM = quantitative susceptibility mapping; SAE = serious adverse event; SEM = standard error of the mean; STN = subthalamic nucleus; TWSTRS = Toronto Western Spasmodic Torticollis Rating Scale.
Article Information

Contributor Notes

Correspondence Robert E. Gross: Emory University School of Medicine, Atlanta, GA. rgross@emory.edu.INCLUDE WHEN CITING Published online October 11, 2019; DOI: 10.3171/2019.6.JNS19548.

V.D.S. and Y.B.B. contributed equally to this work.

Disclosures Dr. Willie received consulting fees from Medtronic, MRI Interventions, Neuropace, and NICO Medical, and research support from Medtronic and Neuropace. Dr. Factor has received honoraria from Biogen, Lundbeck, Teva, Sunovion, Acadia, Neuroderm, Acorda, CereSpir, and Bracket; received grants from Ipsen, Medtronic, Boston Scientific, Teva, US World Meds, Sunovion Therapeutics, Vaccinex, Voyager, Jazz Pharmaceuticals, the CHDI Foundation, the Michael J. Fox Foundation, and NIH (no. U10 NS077366); and received royalties from Demos, Blackwell Futura for textbooks, Springer, and Uptodate. Dr. Boulis is a consultant for Disarm, Axovant Sciences, PTC, Aruna, BlueRock Therapeutics LP, NeuralStem, and Voyager, and is on the Scientific Advisory Board for Renew Biopharma Inc. and CODA. Dr. Gross received consulting fees from Medtronic, St. Jude Medical, MRI Interventions, Abbott, and Boston Scientific, and a research grant from Medtronic and Boston Scientific (these arrangements were approved by Emory University).
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