Improving Targeting in Image-Guided Frame-Based Deep Brain Stimulation

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. ons437-ons447 ◽  
Author(s):  
Etienne M. Holl ◽  
Erika A. Petersen ◽  
Thomas Foltynie ◽  
Irene Martinez-Torres ◽  
Patricia Limousin ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Standard Deviation ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Electrode Placement ◽  
Target Point ◽  
Intended Target ◽  
Image Guided ◽  
Significant Difference ◽  
Deep Brain

ABSTRACT BACKGROUND: Deep brain stimulation (DBS) is commonly used in the treatment of movement disorders such as Parkinson disease (PD), dystonia, and other tremors. OBJECTIVE: To examine systematic errors in image-guided DBS electrode placement and to explore a calibration strategy for stereotactic targeting. METHODS: Pre- and postoperative stereotactic MR images were analyzed in 165 patients. The perpendicular error between planned target coordinates and electrode trajectory was calculated geometrically for all 312 DBS electrodes implanted. Improvement in motor unified PD rating scale III subscore was calculated for those patients with PD with at least 6 months of follow-up after bilateral subthalamic DBS. RESULTS: Mean (standard deviation) scalar error of all electrodes was 1.4(0.9) mm with a significant difference between left and right hemispheres. Targeting error was significantly higher for electrodes with coronal approach angle (ARC) ≥10° (P < .001). Mean vector error was X: −0.6, Y: −0.7, and Z: −0.4 mm (medial, posterior, and superior directions, respectively). Targeting error was significantly improved by using a systematic calibration strategy based on ARC and target hemisphere (mean: 0.6 mm, P < .001) for 47 electrodes implanted in 24 patients. Retrospective theoretical calibration for all 312 electrodes would have reduced the mean (standard deviation) scalar error from 1.4(0.9) mm to 0.9(0.5) mm (36% improvement). With calibration, 97% of all electrodes would be within 2 mm of the intended target as opposed to 81% before calibration. There was no significant correlation between the degree of error and clinical outcome from bilateral subthalamic nucleus DBS (R2 = 0.07). CONCLUSION: After calibration of a systematic targeting error an MR image-guided stereotactic approach would be expected to deliver 97% of all electrodes to within 2 mm of the intended target point with a single brain pass.

Spatial Topographies of Unilateral Subthalamic Nucleus Deep Brain Stimulation Efficacy for Ipsilateral, Contralateral, Midline, and Total Parkinson Disease Motor Symptoms

2015 ◽  
Vol 11 (1) ◽  
pp. 80-88
Author(s):  
Mahesh B Shenai ◽  
Andrew Romeo ◽  
Harrison C Walker ◽  
Stephanie Guthrie ◽  
Ray L Watts ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Electrode Placement ◽  
Kriging Interpolation ◽  
Motor Symptoms ◽  
Disease Rating ◽  
Deep Brain

Abstract BACKGROUND Subthalamic nucleus (STN) deep brain stimulation is a successful intervention for medically refractory Parkinson disease, although its efficacy depends on optimal electrode placement. Even though the predominant effect is observed contralaterally, modest improvements in ipsilateral and midline symptoms are also observed. OBJECTIVE To elucidate the role of contact location of unilateral deep brain stimulation on contralateral, ipsilateral, and axial subscores of Parkinson disease motor symptoms. METHODS Eighty-six patients receiving first deep brain stimulation STN electrode placements were identified, yielding 73 patients with 3-month follow-up. Total preoperative and postoperative Unified Parkinson Disease Rating Scale Part III scores were obtained and divided into contralateral, ipsilateral, and midline subscores. Contact location was determined on immediate postoperative magnetic resonance imaging. A 3-dimensional ordinary “kriging” algorithm generated spatial interpolations for total, ipsilateral, contralateral, and midline symptom categories. Interpolative reconstructions were performed in the axial planes (z = −0.5, −1.0, −1.5, −3.5, −4.5, −6.0) and a sagittal plane (x = 12.0). Interpolation error and significance were quantified by use of a cross-validation technique and quantile-quantile analysis. RESULTS There was an overall reduction in Unified Parkinson Disease Rating Scale Part III symptoms: total = 37.0 ± 24.11% (P < .05), ipsilateral = 15.9 ± 51.8%, contralateral = 56.2 ± 26.8% (P < .05), and midline = 26.5 ± 34.7%. Kriging interpolation was performed and cross-validated with quantile-quantile analysis with high correlation (R2 > 0.92) and demonstrated regions of efficacy for each symptom category. Contralateral symptoms demonstrated broad regions of efficacy across the peri-STN area. The ipsilateral and midline regions of efficacy were constrained and located along the dorsal STN and caudal zona incerta. CONCLUSION We provide evidence for a unique functional topographic window in which contralateral, ipsilateral, and midline structures may achieve the best efficacy. Although there are overlapping regions, laterality demonstrates distinct topographies. Surgical optimization should target the intersection of optimal regions for these symptom categories.

Relationship between higher rates of adverse events in deep brain stimulation using standardized prospective recording and patient outcomes

2010 ◽  
Vol 29 (2) ◽  
pp. E4 ◽  
Author(s):  
Adam P. Burdick ◽  
Hubert H. Fernandez ◽  
Michael S. Okun ◽  
Yueh-Yun Chi ◽  
Charles Jacobson ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Adverse Events ◽  
Motor Function ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Short Form ◽  
Obsessive Compulsive ◽  
Compulsive Disorder ◽  
Significant Difference ◽  
Deep Brain

Object Adverse event (AE) rates for deep brain stimulation (DBS) are variable, due to various methodologies used for identifying, collecting, and reporting AEs. This lack of a prospective, standardized AE collection method is a shortcoming in the advancement of DBS. In this paper the authors disclose the standardized and prospectively recorded AE data from their institution, correlated with clinical outcome and quality of life (QOL) measures. Methods All patients who underwent operations at the authors' institution for Parkinson disease (PD), essential tremor, dystonia, other tremor, and obsessive-compulsive disorder were included. Complications occurring intraoperatively or within the first 180 days following surgery were recorded, analyzed, and classified as mild, moderate, or severe, regardless of their perceived relationship to the procedure. The presence, frequency, and severity of AEs were compared with the following outcome measurements: postoperative change in the QOL scales (Medical Outcomes Study 36-Item Short-Form Survey, 39-Item PD Questionnaire); motor scales (Tremor Rating Scale, Unified Dystonia Rating Scale, Unified PD Rating Scale); and Patient Global Impression Scale (PGIS). Results Two hundred seventy DBS procedures were performed in 198 patients. Three hundred AEs were recorded in 146 (54.1%) of the 270 procedures, and the AEs were recorded in 119 (60.1%) of 198 patients. Of the 198 patients, the maximum severity of AEs was mild in 28 (14.1%), moderate in 35 (17.7%), and severe in 56 (28.3%). Of the 300 AEs, 102 (34.1%) of 299 were mild, 106 (35.5%) were moderate, and 91 (30.4%) were severe. The AEs were classified as probably not stimulation induced in 10 (3.4%) of 297, probably in 44 (14.9%), unclear for 89 (30%), and not applicable to stimulation in 154 (51.9%). Adverse events were also classified as probably related to surgery in 111 (37.2%) of 298, possibly related in 96 (32.2%), and probably not related to surgery in 91 (30.5%). There was no significant difference (p = 0.22) in QOL outcomes among patients who had no AEs compared with those who experienced mild, moderate, or severe AEs. There was no significant difference in QOL outcomes between patients who did not experience an AE compared with those who experienced any AE. There was no significant difference in the mean General PGIS score between patients without an AE versus those with any AE, as well as on the Symptom-Specific PGIS. Motor function outcomes did not vary between patients with or without AEs. For patients with PD with or without AEs, there was no significant difference in preoperative off-medicine Unified PD Rating Scale score and postoperative 6-month on-medication/on-stimulation change scores (p = 0.59). For patients with tremor there were no differences between those with or without AEs on the Tremor Rating Scale for motor function or activities of daily living. Patients with dystonia with and without AEs showed no differences in the Unified Dystonia Rating Scale. Conclusions Prospectively and systematically recording AEs may result in higher AE rates, but this does not correlate with poorer QOL, motor function, or patient-oriented outcome scores.

Accuracy of deep brain stimulation electrode placement using intraoperative computed tomography without microelectrode recording

2013 ◽  
Vol 119 (2) ◽  
pp. 301-306 ◽  
Author(s):  
Kim J. Burchiel ◽  
Shirley McCartney ◽  
Albert Lee ◽  
Ahmed M. Raslan
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Ct Images ◽  
Electrode Placement ◽  
Ventricular Wall ◽  
Mr Images ◽  
Intraoperative Ct ◽  
Vector Error ◽  
Significant Difference ◽  
Deep Brain

Object In this prospective study the authors' objective was to evaluate the accuracy of deep brain stimulation (DBS) electrode placement using image guidance for direct anatomical targeting with intraoperative CT. Methods Preoperative 3-T MR images were merged with intraoperative CT images for planning. Electrode targets were anatomical, based on the MR images. A skull-mounted NexFrame system was used for electrode placement, and all procedures were performed under general anesthesia. After electrode placement, intraoperative CT images were merged with trajectory planning images to calculate accuracy. Accuracy was assessed by both vector error and deviation off the planned trajectory. Results Sixty patients (33 with Parkinson disease, 26 with essential tremor, and 1 with dystonia) underwent the procedure. Patient's mean age was 64 ± 9.5 years. Over an 18-month period, 119 electrodes were placed (all bilateral, except one). Electrode implant locations were the ventral intermediate nucleus (VIM), globus pallidus internus (GPI), and subthalamic nucleus (STN) in 25, 23, and 12 patients, respectively. Target accuracy measurements were as follows: mean vector error 1.59 ± 1.11 mm and mean deviation off trajectory 1.24 ± 0.87 mm. There was no statistically significant difference between the accuracy of left and right brain electrodes. There was a statistically significant (negative) correlation between the distance of the closest approach of the electrode trajectory to the ventricular wall of the lateral ventricle and vector error (r2 = −0.339, p < 0.05, n = 76), and the deviation from the planned trajectory (r2 = −0.325, p < 0.05, n = 77). Furthermore, when the distance from the electrode trajectory and the ventricular wall was < 4 mm, the correlation of the ventricular distance to the deviation from the planned trajectory was stronger (r2 = −0.419, p = 0.05, n = 19). Electrodes placed in the GPI were significantly more accurate than those placed in the VIM (p < 0.05). Only 1 of 119 electrodes required intraoperative replacement due to a vector error > 3 mm. In this series there was one infection and no intraparenchymal hemorrhages. Conclusions Placement of DBS electrodes using an intraoperative CT scanner and the NexFrame achieves an accuracy that is at least comparable to other methods.

Mapping efficacious deep brain stimulation for pediatric dystonia

2021 ◽  
pp. 1-11
Author(s):  
Ailish Coblentz ◽  
Gavin J. B. Elias ◽  
Alexandre Boutet ◽  
Jurgen Germann ◽  
Musleh Algarni ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Clinical Outcome ◽  
Brain Stimulation ◽  
Pediatric Patients ◽  
Rating Scale ◽  
Structural Connectivity ◽  
Response To Treatment ◽  
Internal Globus Pallidus ◽  
Probabilistic Map ◽  
Deep Brain

OBJECTIVEThe objective of this study was to report the authors’ experience with deep brain stimulation (DBS) of the internal globus pallidus (GPi) as a treatment for pediatric dystonia, and to elucidate substrates underlying clinical outcome using state-of-the-art neuroimaging techniques.METHODSA retrospective analysis was conducted in 11 pediatric patients (6 girls and 5 boys, mean age 12 ± 4 years) with medically refractory dystonia who underwent GPi-DBS implantation between June 2009 and September 2017. Using pre- and postoperative MRI, volumes of tissue activated were modeled and weighted by clinical outcome to identify brain regions associated with clinical outcome. Functional and structural networks associated with clinical benefits were also determined using large-scale normative data sets.RESULTSA total of 21 implanted leads were analyzed in 11 patients. The average follow-up duration was 19 ± 20 months (median 5 months). Using a 7-point clinical rating scale, 10 patients showed response to treatment, as defined by scores < 3. The mean improvement in the Burke-Fahn-Marsden Dystonia Rating Scale motor score was 40% ± 23%. The probabilistic map of efficacy showed that the voxel cluster most associated with clinical improvement was located at the posterior aspect of the GPi, comparatively posterior and superior to the coordinates of the classic GPi target. Strong functional and structural connectivity was evident between the probabilistic map and areas such as the precentral and postcentral gyri, parietooccipital cortex, and brainstem.CONCLUSIONSThis study reported on a series of pediatric patients with dystonia in whom GPi-DBS resulted in variable clinical benefit and described a clinically favorable stimulation site for this cohort, as well as its structural and functional connectivity. This information could be valuable for improving surgical planning, simplifying programming, and further informing disease pathophysiology.

scholarly journals Real Color Model of a Cadaver for Deep Brain Stimulation of the Subthalamic Nucleus

2021 ◽  
Vol 11 (11) ◽  
pp. 4999
Author(s):  
Chung-Yoh Kim ◽  
Jin-Seo Park ◽  
Beom-Sun Chung
Keyword(s):  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Magnetic Resonance Images ◽  
Target Point ◽  
Anatomical Structures ◽  
Volume Model ◽  
Segmented Images ◽  
Volume Models ◽  
Deep Brain

When performing deep brain stimulation (DBS) of the subthalamic nucleus, practitioners should interpret the magnetic resonance images (MRI) correctly so they can place the DBS electrode accurately at the target without damaging the other structures. The aim of this study is to provide a real color volume model of a cadaver head that would help medical students and practitioners to better understand the sectional anatomy of DBS surgery. Sectioned images of a cadaver head were reconstructed into a real color volume model with a voxel size of 0.5 mm × 0.5 mm × 0.5 mm. According to preoperative MRIs and postoperative computed tomographys (CT) of 31 patients, a virtual DBS electrode was rendered on the volume model of a cadaver. The volume model was sectioned at the classical and oblique planes to produce real color images. In addition, segmented images of a cadaver head were formed into volume models. On the classical and oblique planes, the anatomical structures around the course of the DBS electrode were identified. The entry point, waypoint, target point, and nearby structures where the DBS electrode could be misplaced were also elucidated. The oblique planes could be understood concretely by comparing the volume model of the sectioned images with that of the segmented images. The real color and high resolution of the volume model enabled observations of minute structures even on the oblique planes. The volume models can be downloaded by users to be correlated with other patients’ data for grasping the anatomical orientation.

Pallidal Deep Brain Stimulation for Primary Dystonia in Children

Neurosurgery ◽  
2011 ◽  
Vol 68 (3) ◽  
pp. 738-743 ◽  
Author(s):  
Abilash Haridas ◽  
Michele Tagliati ◽  
Irene Osborn ◽  
Ioannis Isaias ◽  
Yakov Gologorsky ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Clinical Improvement ◽  
Brain Stimulation ◽  
Functional Disability ◽  
Rating Scale ◽  
Retrospective Chart Review ◽  
Consecutive Series ◽  
Internal Globus Pallidus ◽  
Deep Brain

Abstract BACKGROUND: Deep brain stimulation (DBS) at the internal globus pallidus (GPi) has replaced ablative procedures for the treatment of primary generalized dystonia (PGD) because it is adjustable, reversible, and yields robust clinical improvement that appears to be long lasting. OBJECTIVE: To describe the long-term responses to pallidal DBS of a consecutive series of 22 pediatric patients with PGD. METHODS: Retrospective chart review of 22 consecutive PGD patients, ≤21 years of age treated by one DBS team over an 8-year period. The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) was used to evaluate symptom severity and functional disability, pre- and post-operatively. Adverse events and medication changes were also noted. RESULTS: The median follow-up was 2 years (range, 1-8 years). All 22 patients reached 1-year follow-up; 14 reached 2 years, and 11 reached 3 years. The BFMDRS motor subscores were improved 84%, 93%, and 94% (median) at these time points. These motor responses were matched by equivalent improvements in function, and the response to DBS resulted in significant reductions in oral and intrathecal medication requirements after 12 and 24 months of stimulation. There were no hemorrhages or neurological complications related to surgery and no adverse effects from stimulation. Significant hardware-related complications were noted, in particular, infection (14%), which delayed clinical improvement. CONCLUSION: Pallidal DBS is a safe and effective treatment for PGD in patients &lt;21 years of age. The improvement appears durable. Improvement in device design should reduce hardware-related complications over time.

Clinical outcomes of asleep vs awake deep brain stimulation for Parkinson disease

Neurology ◽  
2017 ◽  
Vol 89 (19) ◽  
pp. 1944-1950 ◽  
Author(s):  
Matthew A. Brodsky ◽  
Shannon Anderson ◽  
Charles Murchison ◽  
Mara Seier ◽  
Jennifer Wilhelm ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Brain Stimulation ◽  
Electrode Placement ◽  
Microelectrode Recording ◽  
Imaging Guidance ◽  
Motor Outcomes ◽  
Deep Brain

Objective:To compare motor and nonmotor outcomes at 6 months of asleep deep brain stimulation (DBS) for Parkinson disease (PD) using intraoperative imaging guidance to confirm electrode placement vs awake DBS using microelectrode recording to confirm electrode placement.Methods:DBS candidates with PD referred to Oregon Health & Science University underwent asleep DBS with imaging guidance. Six-month outcomes were compared to those of patients who previously underwent awake DBS by the same surgeon and center. Assessments included an “off”-levodopa Unified Parkinson’s Disease Rating Scale (UPDRS) II and III, the 39-item Parkinson's Disease Questionnaire, motor diaries, and speech fluency.Results:Thirty participants underwent asleep DBS and 39 underwent awake DBS. No difference was observed in improvement of UPDRS III (+14.8 ± 8.9 vs +17.6 ± 12.3 points, p = 0.19) or UPDRS II (+9.3 ± 2.7 vs +7.4 ± 5.8 points, p = 0.16). Improvement in “on” time without dyskinesia was superior in asleep DBS (+6.4 ± 3.0 h/d vs +1.7 ± 1.2 h/d, p = 0.002). Quality of life scores improved in both groups (+18.8 ± 9.4 in awake, +8.9 ± 11.5 in asleep). Improvement in summary index (p = 0.004) and subscores for cognition (p = 0.011) and communication (p < 0.001) were superior in asleep DBS. Speech outcomes were superior in asleep DBS, both in category (+2.77 ± 4.3 points vs −6.31 ± 9.7 points (p = 0.0012) and phonemic fluency (+1.0 ± 8.2 points vs −5.5 ± 9.6 points, p = 0.038).Conclusions:Asleep DBS for PD improved motor outcomes over 6 months on par with or better than awake DBS, was superior with regard to speech fluency and quality of life, and should be an option considered for all patients who are candidates for this treatment.Clinicaltrials.gov identifier:NCT01703598.Classification of evidence:This study provides Class III evidence that for patients with PD undergoing DBS, asleep intraoperative CT imaging–guided implantation is not significantly different from awake microelectrode recording–guided implantation in improving motor outcomes at 6 months.

scholarly journals Pediatric Deep Brain Stimulation Using Awake Recording and Stimulation for Target Selection in an Inpatient Neuromodulation Monitoring Unit

2018 ◽  
Vol 8 (7) ◽  
pp. 135 ◽  
Author(s):  
Terence D. Sanger ◽  
Mark Liker ◽  
Enrique Arguelles ◽  
Ruta Deshpande ◽  
Arash Maskooki ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Basal Ganglia ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Target Selection ◽  
Test Stimulation ◽  
Depth Electrodes ◽  
A New Technique ◽  
High Degree ◽  
Deep Brain

Deep brain stimulation (DBS) for secondary (acquired, combined) dystonia does not reach the high degree of efficacy achieved in primary (genetic, isolated) dystonia. We hypothesize that this may be due to variability in the underlying injury, so that different children may require placement of electrodes in different regions of basal ganglia and thalamus. We describe a new targeting procedure in which temporary depth electrodes are placed at multiple possible targets in basal ganglia and thalamus, and probing for efficacy is performed using test stimulation and recording while children remain for one week in an inpatient Neuromodulation Monitoring Unit (NMU). Nine Children with severe secondary dystonia underwent the NMU targeting procedure. In all cases, 4 electrodes were implanted. We compared the results to 6 children who had previously had 4 electrodes implanted using standard intraoperative microelectrode targeting techniques. Results showed a significant benefit, with 80% of children with NMU targeting achieving greater than 5-point improvement on the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), compared with 50% of children using intraoperative targeting. NMU targeting improved BFMDRS by an average of 17.1 whereas intraoperative targeting improved by an average of 10.3. These preliminary results support the use of test stimulation and recording in a Neuromodulation Monitoring Unit (NMU) as a new technique with the potential to improve outcomes following DBS in children with secondary (acquired) dystonia. A larger sample size will be needed to confirm these results.

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

2009 ◽  
Vol 110 (6) ◽  
pp. 1283-1290 ◽  
Author(s):  
Ludvic Zrinzo ◽  
Arjen L. J. van Hulzen ◽  
Alessandra A. Gorgulho ◽  
Patricia Limousin ◽  
Michiel J. Staal ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Electrode Placement ◽  
Neurosurgical Procedures ◽  
Electrode Implantation ◽  
Clinical Observations ◽  
Simple Step ◽  
The Mean ◽  
The Impact ◽  
Deep Brain

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.

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