The Poised Cannula Technique Reduces the Stereotactic Error of the Fiducial-Less Frameless DBS Procedure

2021 ◽  
pp. 1-9
Author(s):  
Matthew Moser ◽  
Paul Koch ◽  
Harsh P. Shah ◽  
Alen Docef ◽  
Kathryn L. Holloway
Keyword(s):  
Low Dose ◽  
Radial Error ◽  
Lead Placement ◽  
Center Channel ◽  
Time Correction ◽  
Clinically Significant ◽  
Lead Location ◽  
Target Depth ◽  
Potentially Clinically Significant ◽  
Deep Brain

<b><i>Background:</i></b> In this study, we describe a technique of optimizing the accuracy of frameless deep brain stimulation (DBS) lead placement through the use of a cannula poised at the entry to predict the location of the fully inserted device. This allows real-time correction of error prior to violation of the deep gray matter. <b><i>Methods:</i></b> We prospectively gathered data on radial error during the operative placements of 40 leads in 28 patients using frameless fiducial-less DBS surgery. Once the Nexframe had been aligned to target, a cannula was inserted through the center channel of the BenGun until it traversed the pial surface and a low-dose O-arm spin was obtained. Using 2 points along the length of the imaged cannula, a trajectory line was projected to target depth. If lead location could be improved, the cannula was inserted through an alternate track in the BenGun down to target depth. After intraoperative microelectrode recording and clinical assessment, another O-arm spin was obtained to compare the location of the inserted lead with the location predicted by the poised cannula. <b><i>Results:</i></b> The poised cannula projection and the actual implant had a mean radial discrepancy of 0.75 ± 0.64 mm. The poised cannula projection identified potentially clinically significant errors (avg 2.07 ± 0.73 mm) in 33% of cases, which were reduced to a radial error of 1.33 ± 0.66 mm (<i>p</i> = 0.02) after correction using an alternative BenGun track. The final target to implant error for all 40 leads was 1.20 ± 0.52 mm with only 2.5% of errors being &#x3e;2.5 mm. <b><i>Conclusion:</i></b> The poised cannula technique results in a reduction of large errors (&#x3e;2.5 mm), resulting in a decline in these errors to 2.5% of implants as compared to 17% in our previous publication using the fiducial-less method and 4% using fiducial-based methods of DBS lead placement.

scholarly journals Microstimulation Is a Promising Approach in Achieving Better Lead Placement in Subthalamic Nucleus Deep Brain Stimulation Surgery

2021 ◽  
Vol 12 ◽  
Author(s):  
Lin Shi ◽  
Shiying Fan ◽  
Tianshuo Yuan ◽  
Huaying Fang ◽  
Jie Zheng ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Neuronal Firing ◽  
Lead Placement ◽  
Imaging Reconstruction ◽  
Neurophysiological Data ◽  
Lead Location ◽  
Deep Brain Stimulation Surgery ◽  
Deep Brain

Background: The successful application of subthalamic nucleus (STN) deep brain stimulation (DBS) surgery relies mostly on optimal lead placement, whereas the major challenge is how to precisely localize STN. Microstimulation, which can induce differentiating inhibitory responses between STN and substantia nigra pars reticulata (SNr) near the ventral border of STN, has indicated a great potential of breaking through this barrier.Objective: This study aims to investigate the feasibility of localizing the boundary between STN and SNr (SSB) using microstimulation and promote better lead placement.Methods: We recorded neurophysiological data from 41 patients undergoing STN-DBS surgery with microstimulation in our hospital. Trajectories with typical STN signal were included. Microstimulation was applied near the bottom of STN to determine SSB, which was validated by the imaging reconstruction of DBS leads.Results: In most trajectories with microstimulation (84.4%), neuronal firing in STN could not be inhibited by microstimulation, whereas in SNr long inhibition was observed following microstimulation. The success rate of localizing SSB was significantly higher in trajectories with microstimulation than those without. Moreover, results from imaging reconstruction and intraoperative neurological assessments demonstrated better lead location and higher therapeutic effectiveness in trajectories with microstimulation and accurately identified SSB.Conclusion: Microstimulation on microelectrode recording is an effective approach to localize the SSB. Our data provide clinical evidence that microstimulation can be routinely employed to achieve better lead placement.

scholarly journals Recurrent, Delayed Hemorrhage Associated with Edoxaban after Deep Brain Stimulation Lead Placement

2013 ◽  
Vol 2013 ◽  
pp. 1-4
Author(s):  
Walavan Sivakumar ◽  
Sarah T. Garber ◽  
Lauren E. Schrock ◽  
Paul A. House
Keyword(s):  
Atrial Fibrillation ◽  
Relative Risk ◽  
Factor Xa ◽  
Deep Brain Stimulator ◽  
Intracranial Surgery ◽  
Systemic Embolization ◽  
Lead Placement ◽  
Delayed Hemorrhage ◽  
Clinically Significant ◽  
Deep Brain

Factor-Xa inhibitors like edoxaban have been shown to have comparable or superior rates of stroke and systemic embolization prevention to warfarin while exhibiting lower clinically significant bleeding rates. The authors report a case of a man who presented with delayed, recurrent intracranial hemorrhage months after successful deep brain stimulator placement for Parkinson disease while on edoxaban for atrial fibrillation. Further reports on the use of novel anticoagulants after intracranial surgery are acutely needed to help assess the true relative risk they pose.

scholarly journals Stereotactic ROBOT-Assisted Deep Brain Stimulation Workflow: Incorporating the ROSA-Brain System Into the Functional Neurosurgical Practice

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Amir H Faraji ◽  
Vasileios Kokkinos ◽  
James C Sweat ◽  
Robert M Richardson
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Human Error ◽  
Neurosurgical Procedures ◽  
Robotic Assisted ◽  
Microelectrode Recordings ◽  
Radial Error ◽  
Lead Placement ◽  
Significant Difference ◽  
Deep Brain

Abstract INTRODUCTION Modern robotic-assisted stereotaxy has been increasingly adopted for neurosurgical procedures. Accuracy and precision are paramount in deep brain stimulation (DBS) surgery, and robotic control may improve surgical outcomes and precision. We developed 2 frame-based workflows for DBS: (1) without microelectrode recordings and (2) with microelectrode recordings and the possibility for intraoperative electrocorticography, and reported on lead placement accuracy and complications. METHODS A consecutive single-surgeon cohort of 20 patients underwent stage 1 DBS (targets included VIM, STN, GPi) with frame-based ROSA-Brain robotic assistance. Radial error accuracy was retrospectively established with two blinded raters comparing pre- and postoperative DBS lead trajectories. Total operative case time was obtained from nursing documentation and postoperative complications were documented. RESULTS A systematic method for ROSA-Brain co-registration was developed to allow for DBS: (1) without microelectrode recordings and (2) with microelectrode recordings and the possibility for intraoperative electrocorticography. The overall radial error for lead placement across all 20 patients was 1.14+/−0.11 mm. A significant difference (P = .006) existed between the radial error of the first 10 patients (1.46+/−0.19 mm) as compared to the second 10 patients (0.86+/−0.09 mm). Overall, the total OR case time is at par with previously reported robotic-assisted DBS cases. CONCLUSION Robotic-assisted DBS surgery, such as with the ROSA-Brain platform, has the potential to increase precision and reduce the human error associated with multiple measurements using traditional frame-based surgery without significantly impacting operating room workflow.

Interventional MRI–guided deep brain stimulation in pediatric dystonia: first experience with the ClearPoint system

2014 ◽  
Vol 14 (4) ◽  
pp. 400-408 ◽  
Author(s):  
Philip A. Starr ◽  
Leslie C. Markun ◽  
Paul S. Larson ◽  
Monica M. Volz ◽  
Alastair J. Martin ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Adverse Events ◽  
Real Time ◽  
Brain Stimulation ◽  
Interventional Mri ◽  
Lead Placement ◽  
The Mean ◽  
Mri Guided ◽  
Lead Location ◽  
Deep Brain

Object The placement of deep brain stimulation (DBS) leads in adults is traditionally performed using physiological confirmation of lead location in the awake patient. Most children are unable to tolerate awake surgery, which poses a challenge for intraoperative confirmation of lead location. The authors have developed an interventional MRI (iMRI)–guided procedure to allow for real-time anatomical imaging, with the goal of achieving very accurate lead placement in patients who are under general anesthesia. Methods Six pediatric patients with primary dystonia were prospectively enrolled. Patients were candidates for surgery if they had marked disability and medical therapy had been ineffective. Five patients had the DYT1 mutation, and mean age at surgery was 11.0 ± 2.8 years. Patients underwent bilateral globus pallidus internus (GPi, n = 5) or sub-thalamic nucleus (STN, n = 1) DBS. The leads were implanted using a novel skull-mounted aiming device in conjunction with dedicated software (ClearPoint system), used within a 1.5-T diagnostic MRI unit in a radiology suite, without physiological testing. The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) was used at baseline, 6 months, and 12 months postoperatively. Further measures included lead placement accuracy, quality of life, adverse events, and stimulation settings. Results A single brain penetration was used for placement of all 12 leads. The mean difference (± SD) between the intended target location and the actual lead location, in the axial plane passing through the intended target, was 0.6 ± 0.5 mm, and the mean surgical time (leads only) was 190 ± 26 minutes. The mean percent improvement in the BFMDRS movement scores was 86.1% ± 12.5% at 6 months (n = 6, p = 0.028) and 87.6% ± 19.2% at 12 months (p = 0.028). The mean stimulation settings at 12 months were 3.0 V, 83 μsec, 135 Hz for GPi DBS, and 2.1 V, 60 μsec, 145 Hz for STN DBS). There were no serious adverse events. Conclusions Interventional MRI–guided DBS using the ClearPoint system was extremely accurate, provided real-time confirmation of DBS placement, and could be used in any diagnostic MRI suite. Clinical outcomes for pediatric dystonia are comparable with the best reported results using traditional frame-based stereotaxy. Clinical trial registration no.: NCT00792532 (ClinicalTrials.gov).

scholarly journals Robotic-Assisted Stereotaxy for Deep Brain Stimulation Lead Implantation in Awake Patients

2020 ◽  
Vol 19 (4) ◽  
pp. 444-452 ◽  
Author(s):  
Amir H Faraji ◽  
Vasileios Kokkinos ◽  
James C Sweat ◽  
Donald J Crammond ◽  
R Mark Richardson
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Human Error ◽  
Robotic Assisted ◽  
Radial Error ◽  
Accuracy And Precision ◽  
Lead Placement ◽  
Significant Difference ◽  
Novel Method ◽  
Deep Brain

Abstract BACKGROUND Robotic-assisted stereotaxy has been increasingly adopted for lead implantation in stereoelectroencephalography based on its efficiency, accuracy, and precision. Despite initially being developed for use in deep brain stimulation (DBS) surgery, adoption for this indication has not been widespread. OBJECTIVE To describe a recent robotic-assisted stereotaxy experience and workflow for DBS lead implantation in awake patients with and without microelectrode recording (MER), including considerations for intraoperative research using electrocorticography (ECoG). METHODS A retrospective review of 20 consecutive patients who underwent simultaneous bilateral DBS lead implantation using robotic-assisted stereotaxy was performed. Radial error was determined by comparing the preoperative target with the DBS lead position in the targeting plane on postoperative computed tomography. Information regarding any postoperative complications was obtained by chart review. RESULTS A novel method for robot coregistration was developed. We describe a standard workflow that allows for MER and/or ECoG research, and a streamlined workflow for cases in which MER is not required. The overall radial error for lead placement across all 20 patients was 1.14 ± 0.11 mm. A significant difference (P = .006) existed between the radial error of the first 10 patients (1.46 ± 0.19 mm) as compared with the second 10 patients (0.86 ± 0.09 mm). No complications were encountered. CONCLUSION Robotic-assisted stereotaxy has the potential to increase precision and reduce human error, compared to traditional frame-based DBS surgery, without negatively impacting patient safety or the ability to perform awake neurophysiology research.

Asleep deep brain stimulation with intraoperative magnetic resonance guidance: a single-institution experience

2021 ◽  
pp. 1-10
Author(s):  
David J. Segar ◽  
Nalini Tata ◽  
Maya Harary ◽  
Michael T. Hayes ◽  
G. Rees Cosgrove
Keyword(s):  
Deep Brain Stimulation ◽  
General Anesthesia ◽  
Brain Stimulation ◽  
Operative Time ◽  
Radial Error ◽  
Technical Accuracy ◽  
Lead Placement ◽  
Surgeon Experience ◽  
Deep Brain

OBJECTIVE Deep brain stimulation (DBS) is traditionally performed on an awake patient with intraoperative recordings and test stimulation. DBS performed under general anesthesia with intraoperative MRI (iMRI) has demonstrated high target accuracy, reduced operative time, direct confirmation of target placement, and the ability to place electrodes without cessation of medications. The authors describe their initial experience with using iMRI to perform asleep DBS and discuss the procedural and radiological outcomes of this procedure. METHODS All DBS electrodes were implanted under general anesthesia by a single surgeon by using a neuronavigation system with 3-T iMRI guidance. Clinical outcomes, operative duration, complications, and accuracy were retrospectively analyzed. RESULTS In total, 103 patients treated from 2015 to 2019 were included, and all but 1 patient underwent bilateral implantation. Indications included Parkinson’s disease (PD) (65% of patients), essential tremor (ET) (29%), dystonia (5%), and refractory epilepsy (1%). Targets included the globus pallidus pars internus (12.62% of patients), subthalamic nucleus (56.31%), ventral intermedius nucleus of the thalamus (30%), and anterior nucleus of the thalamus (1%). Technically accurate lead placement (radial error ≤ 1 mm) was obtained for 98% of leads, with a mean (95% CI) radial error of 0.50 (0.46–0.54) mm; all leads were placed with a single pass. Predicted radial error was an excellent predictor of real radial error, underestimating real error by only a mean (95% CI) of 0.16 (0.12–0.20) mm. Accuracy remained high irrespective of surgeon experience, but procedure time decreased significantly with increasing institutional and surgeon experience (p = 0.007), with a mean procedure duration of 3.65 hours. Complications included 1 case of intracranial hemorrhage (asymptomatic) and 1 case of venous infarction (symptomatic), and 2 patients had infection at the internal pulse generator site. The mean ± SD voltage was 2.92 ± 0.83 V bilaterally at 1-year follow-up. Analysis of long-term clinical efficacy demonstrated consistent postoperative improvement in clinical symptoms, as well as decreased drug doses across all indications and follow-up time points, including mean decrease in levodopa-equivalent daily dose by 53.57% (p < 0.0001) in PD patients and mean decrease in primidone dose by 61.33% (p < 0.032) in ET patients at 1-year follow-up. CONCLUSIONS A total of 205 leads were placed in 103 patients by a single surgeon under iMRI guidance with few operative complications. Operative time trended downward with increasing institutional experience, and technical accuracy of radiographic lead placement was consistently high. Asleep DBS implantation with iMRI appears to be a safe and effective alternative to standard awake procedures.

scholarly journals Two Hundred Twenty-Six Consecutive Deep Brain Stimulation Electrodes Placed Using an “Asleep” Technique and the Neuro|MateTM Robot for the Treatment of Movement Disorders

2020 ◽  
Vol 19 (5) ◽  
pp. 530-538
Author(s):  
Catherine Moran ◽  
Nagaraja Sarangmat ◽  
Carter S Gerard ◽  
Neil Barua ◽  
Reiko Ashida ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Movement Disorders ◽  
Zona Incerta ◽  
Angular Error ◽  
Electrode Placement ◽  
Radial Error ◽  
Lead Placement ◽  
The Mean ◽  
Deep Brain

Abstract BACKGROUND Robotics in neurosurgery has demonstrated widening indications and rapid growth in recent years. Robotic precision and reproducibility are especially pertinent to the field of functional neurosurgery. Deep brain stimulation (DBS) requires accurate placement of electrodes in order to maximize efficacy and minimize side effects. In addition, asleep techniques demand clear target visualization and immediate on-table verification of accuracy. OBJECTIVE To describe the surgical technique of asleep DBS surgery using the Neuro|MateTM Robot (Renishaw plc, Wotton-under-Edge, United Kingdom) and examine the accuracy of DBS lead placement in the subthalamic nucleus (STN) for the treatment of movement disorders. METHODS A single-center retrospective review of 113 patients who underwent bilateral STN/Zona Incerta electrode placement was performed. Accuracy of implantation was assessed using 5 measurements, Euclidian distance, radial error, depth error, angular error, and shift error. RESULTS A total of 226 planned vs actual electrode placements were analyzed. The mean 3-dimensional vector error calculated for 226 trajectories was 0.78 +/− 0.37 mm. The mean radial displacement off planned trajectory was 0.6 +/− 0.33 mm. The mean depth error, angular error, and shift error was 0.4 +/− 0.35 mm, 0.4 degrees, and 0.3 mm, respectively. CONCLUSION This report details our institution's method for DBS lead placement in patients under general anaesthesia using anatomical targeting without microelectrode recordings or intraoperative test stimulation for the treatment of movement disorders. This is the largest reported dataset of accuracy results in DBS surgery performed asleep. This novel robot-assisted operative technique results in sub-millimeter accuracy in DBS electrode placement.

scholarly journals Pallidal stimulation as treatment for camptocormia in Parkinson’s disease

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Yijie Lai ◽  
Yunhai Song ◽  
Daoqing Su ◽  
Linbin Wang ◽  
Chencheng Zhang ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Case Reports ◽  
Structural Connectivity ◽  
Video Recordings ◽  
Lead Placement ◽  
Pallidal Stimulation ◽  
The Impact ◽  
Deep Brain

AbstractCamptocormia is a common and often debilitating postural deformity in Parkinson’s disease (PD). Few treatments are currently effective. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) shows potential in treating camptocormia, but evidence remains limited to case reports. We herein investigate the effect of GPi-DBS for treating camptocormia in a retrospective PD cohort. Thirty-six consecutive PD patients who underwent GPi-DBS were reviewed. The total and upper camptocormia angles (TCC and UCC angles) derived from video recordings of patients who received GPi-DBS were used to compare camptocormia alterations. Correlation analysis was performed to identify factors associated with the postoperative improvements. DBS lead placement and the impact of stimulation were analyzed using Lead-DBS software. Eleven patients manifested pre-surgical camptocormia: seven had lower camptocormia (TCC angles ≥ 30°; TCC-camptocormia), three had upper camptocormia (UCC angles ≥ 45°; UCC-camptocormia), and one had both. Mean follow-up time was 7.3 ± 3.3 months. GPi-DBS improved TCC-camptocormia by 40.4% (angles from 39.1° ± 10.1° to 23.3° ± 8.1°, p = 0.017) and UCC-camptocormia by 22.8% (angles from 50.5° ± 2.6° to 39.0° ± 6.7°, p = 0.012). Improvement in TCC angle was positively associated with pre-surgical TCC angles, levodopa responsiveness of the TCC angle, and structural connectivity from volume of tissue activated to somatosensory cortex. Greater improvement in UCC angles was seen in patients with larger pre-surgical UCC angles. Our study demonstrates potential effectiveness of GPi-DBS for treating camptocormia in PD patients. Future controlled studies with larger numbers of patients with PD-related camptocormia should extend our findings.

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