Imaging for deep brain stimulation: The zona incerta at 7 Tesla

Introduction: Deep brain stimulation of the zona incerta is effective at treating tremor and other forms of parkinsonism. However, the structure is not well visualized with standard MRI protocols making direct surgical targeting unfeasible and contributing to inconsistent clinical outcomes. In this study, we applied coronal gradient echo MRI to directly visualize the rostral zona incerta in Parkinson’s disease patients to improve targeting for deep brain stimulation. Methods: We conducted a prospective study to optimize and evaluate an MRI sequence to visualize the rostral zona incerta in patients with Parkinson’s disease (n = 31) and other movement disorders (n = 13). We performed a contrast-to-noise ratio analysis of specific regions of interest to quantitatively assess visual discrimination of relevant deep brain structures in the optimized MRI sequence. Regions of interest were independently assessed by 2 neuroradiologists, and interrater reliability was assessed. Results: Rostral zona incerta and subthalamic nucleus were well delineated in our 5.5-min MRI sequence, indicated by excellent interrater agreement between neuroradiologists for region-of-interest measurements (>0.90 intraclass coefficient). Mean contrast-to-noise ratio was high for both rostral zona incerta (6.39 ± 3.37) and subthalamic nucleus (17.27 ± 5.61) relative to adjacent white matter. There was no significant difference between mean signal intensities or contrast-to-noise ratio for Parkinson’s and non-Parkinson’s patients for either structure. Discussion/Conclusion: Our optimized coronal gradient echo MRI sequence delineates subcortical structures relevant to traditional and novel deep brain stimulation targets, including the zona incerta, with high contrast-to-noise. Future studies will prospectively apply this sequence to surgical planning and postimplantation outcomes.

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Speech Function Following Deep Brain Stimulation of the Caudal Zona Incerta: Effects of Habitual and High-Amplitude Stimulation

Journal of Speech Language and Hearing Research ◽

10.1044/2020_jslhr-20-00256 ◽

2021 ◽

pp. 1-13

Author(s):

Linda Sandström ◽

Ellika Schalling ◽

Fredrik Karlsson ◽

Patric Blomstedt ◽

Lena Hartelius

Keyword(s):

Deep Brain Stimulation ◽

Brain Stimulation ◽

High Amplitude ◽

Nonparametric Tests ◽

Zona Incerta ◽

Maximal Amplitude ◽

Significant Group ◽

Preliminary Study ◽

Deep Brain ◽

Stimulation Of

Purpose Deep brain stimulation (DBS) is often successful in alleviating motor symptoms of essential tremor (ET); however, DBS may also induce adverse speech effects. The caudal zona incerta (cZi) is a promising DBS target for tremor, but less is known about the consequences of cZi DBS for speech. This preliminary study examined how habitual cZi DBS and cZi stimulation at high amplitudes may affect speech function in persons with ET. Method Fourteen participants with ET were evaluated: off stimulation, on habitual cZi DBS, and with unilateral cZi stimulation at increasing stimulation amplitudes. At each stimulation condition, the participants read three 16-word sentences. Two speech-language pathologists made audio-perceptual consensus ratings of overall speech function, articulation, and voice using a visual sort and rate method. Rated functions when off stimulation, on habitual cZi DBS, and at maximal-amplitude stimulation were compared using Friedman nonparametric tests. For participants with bilateral habitual DBS ( n = 5), the effects of bilateral and unilateral stimulation were described in qualitative terms. Results Habitual cZi DBS had no significant group-level effect on any of the investigated speech parameters. Maximal-amplitude stimulation had a small but significant negative effect on articulation. Participants with reduced articulatory precision ( n = 9) had more medially placed electrodes than the nonaffected group ( n = 5). Bilateral and unilateral left stimulation had comparable effects on speech. Conclusions Findings from this preliminary study of cZi DBS indicate that speech is generally not affected by stimulation at habitual levels. High-amplitude cZi stimulation may, however, induce adverse effects, particularly on articulation. Instances of decreased articulatory function were associated with stimulation of more medial electrode contacts, which could suggest cerebello-rubrospinal involvement.

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Unilateral Left Deep Brain Stimulation of the Caudal Zona Incerta Is Equally Effective on Voice Tremor as Bilateral Stimulation: Evidence from 7 Patients with Essential Tremor

Stereotactic and Functional Neurosurgery ◽

10.1159/000489938 ◽

2018 ◽

Vol 96 (3) ◽

pp. 157-161 ◽

Cited By ~ 4

Author(s):

Linda Sandström ◽

Fredrik Karlsson ◽

Patric Blomstedt

Keyword(s):

Deep Brain Stimulation ◽

Essential Tremor ◽

Brain Stimulation ◽

Zona Incerta ◽

Bilateral Stimulation ◽

Deep Brain ◽

Stimulation Of

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Stimulation-Induced Dyskinesia, Interleaving Settings, and Management of Subthalamic Nucleus Deep Brain Stimulation in DYT1 Dystonia

Deep Brain Stimulation ◽

10.1093/med/9780190647209.003.0038 ◽

2020 ◽

pp. 201-204

Author(s):

Kyle T. Mitchell ◽

Kristen A. Dodenhoff ◽

Philip A. Starr ◽

Jill L. Ostrem

Keyword(s):

Deep Brain Stimulation ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Complete Resolution ◽

Symptomatic Improvement ◽

Zona Incerta ◽

Dyt1 Dystonia ◽

Primary Dystonia ◽

Stn Dbs ◽

Deep Brain

DYT1 dystonia is a primary dystonia with potential for significant symptomatic improvement after bilateral deep brain stimulation (DBS) of the globus pallidus interna (GPi). GPi is the historical target of choice for this disease. This chapter presents a case of an adolescent with disabling generalized DYT1 dystonia who underwent bilateral subthalamic nucleus (STN) DBS as part of a prospective clinical trial. While limb and cervical dystonia dramatically improved with DBS, programming was limited by stimulation-induced bilateral limb dyskinesia, including in the left arm, which was previously unaffected by dystonia. After years of evolving symptoms and complex programming, bilateral interleaved settings using both a contact in motor STN and the most dorsal DBS contact in the zona incerta resulted in sustained, near-complete resolution of dystonia without side effects. This case illustrates the use of the STN as an effective DBS target for primary dystonia, although complex programming was necessary to mitigate stimulation-induced dyskinesia.

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Deep-Brain Stimulation for Essential Tremor and Other Tremor Syndromes: A Narrative Review of Current Targets and Clinical Outcomes

Brain Sciences ◽

10.3390/brainsci10120925 ◽

2020 ◽

Vol 10 (12) ◽

pp. 925

Author(s):

Christian Iorio-Morin ◽

Anton Fomenko ◽

Suneil K. Kalia

Keyword(s):

Multiple Sclerosis ◽

Deep Brain Stimulation ◽

Essential Tremor ◽

Brain Stimulation ◽

Zona Incerta ◽

Future Directions ◽

Ventral Intermediate Nucleus ◽

Prevalent Symptom ◽

Multiple Conditions ◽

Deep Brain

Tremor is a prevalent symptom associated with multiple conditions, including essential tremor (ET), Parkinson’s disease (PD), multiple sclerosis (MS), stroke and trauma. The surgical management of tremor evolved from stereotactic lesions to deep-brain stimulation (DBS), which allowed safe and reversible interference with specific neural networks. This paper reviews the current literature on DBS for tremor, starting with a detailed discussion of current tremor targets (ventral intermediate nucleus of the thalamus (Vim), prelemniscal radiations (Raprl), caudal zona incerta (Zi), thalamus (Vo) and subthalamic nucleus (STN)) and continuing with a discussion of results obtained when performing DBS in the various aforementioned tremor syndromes. Future directions for DBS research are then briefly discussed.

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An Assessment of Current Brain Targets for Deep Brain Stimulation Surgery With Susceptibility-Weighted Imaging at 7 Tesla

Neurosurgery ◽

10.1227/neu.0b013e3181f74105 ◽

2010 ◽

Vol 67 (6) ◽

pp. 1745-1756 ◽

Cited By ~ 143

Author(s):

Aviva Abosch ◽

Essa Yacoub ◽

Kamil Ugurbil ◽

Noam Harel

Keyword(s):

Deep Brain Stimulation ◽

Brain Stimulation ◽

Image Resolution ◽

7 Tesla ◽

Patient Specific ◽

Susceptibility Weighted Imaging ◽

Target Area ◽

Electrode Position ◽

Microelectrode Recording ◽

Deep Brain

Abstract BACKGROUND: Deep brain stimulation (DBS) surgery is used for treating movement disorders, including Parkinson disease, essential tremor, and dystonia. Successful DBS surgery is critically dependent on precise placement of DBS electrodes into target structures. Frequently, DBS surgery relies on normalized atlas-derived diagrams that are superimposed on patient brain magnetic resonance imaging (MRI) scans, followed by microelectrode recording and macrostimulation to refine the ultimate electrode position. Microelectrode recording carries a risk of hemorrhage and requires active patient participation during surgery. OBJECTIVE: To enhance anatomic imaging for DBS surgery using high-field MRI with the ultimate goal of improving the accuracy of anatomic target selection. METHODS: Using a 7-T MRI scanner combined with an array of acquisition schemes using multiple image contrasts, we obtained high-resolution images of human deep nuclei in healthy subjects. RESULTS: Superior image resolution and contrast obtained at 7 T in vivo using susceptibility-weighted imaging dramatically improved anatomic delineation of DBS targets and allowed the identification of internal architecture within these targets. A patient-specific, 3-dimensional model of each target area was generated on the basis of the acquired images. CONCLUSION: Technical developments in MRI at 7 T have yielded improved anatomic resolution of deep brain structures, thereby holding the promise of improving anatomic-based targeting for DBS surgery. Future study is needed to validate this technique in improving the accuracy of targeting in DBS surgery.

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Deep Brain Stimulation of the Caudal Zona Incerta and Motor Thalamus for Postischemic Dystonic Tremor of the Left Upper Limb: Case Report and Review of the Literature

World Neurosurgery ◽

10.1016/j.wneu.2019.01.183 ◽

2019 ◽

Vol 125 ◽

pp. 191-197 ◽

Cited By ~ 3

Author(s):

Davide Bagatti ◽

Antonio D'Ammando ◽

Angelo Franzini ◽

Giuseppe Messina

Keyword(s):

Case Report ◽

Deep Brain Stimulation ◽

Upper Limb ◽

Brain Stimulation ◽

Zona Incerta ◽

Review Of The Literature ◽

Dystonic Tremor ◽

Motor Thalamus ◽

Deep Brain ◽

Stimulation Of

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Postmortem analysis following 71 months of deep brain stimulation of the subthalamic nucleus for Parkinson disease

Journal of Neurosurgery ◽

10.3171/jns/2008/109/8/0325 ◽

2008 ◽

Vol 109 (2) ◽

pp. 325-329 ◽

Cited By ~ 38

Author(s):

David A. Sun ◽

Hong Yu ◽

John Spooner ◽

Armanda D. Tatsas ◽

Thomas Davis ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Tissue Reaction ◽

Tissue Response ◽

Zona Incerta ◽

Foreign Body Giant Cell ◽

Stn Dbs ◽

Deep Brain

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a clinically effective neurosurgical treatment for Parkinson disease. Tissue reaction to chronic DBS therapy and the definitive location of active stimulation contacts are best studied on a postmortem basis in patients who have undergone DBS. The authors report the postmortem analysis of STN DBS following 5 years and 11 months of effective chronic stimulation including the histologically verified location of the active contacts associated with bilateral implants. They also describe tissue response to intraoperative test passes with recording microelectrodes and stimulating semimacroelectrodes. The results indicated that 1) the neural tissue surrounding active and nonactive contacts responds similarly, with a thin glial capsule and foreign-body giant cell reaction surrounding the leads as well as piloid gliosis, hemosiderin-laden macrophages, scattered lymphocytes, and Rosenthal fibers; 2) there was evidence of separate tracts in the adjacent tissue for intraoperative microelectrode and semimacroelectrode passes together with reactive gliosis, microcystic degeneration, and scattered hemosiderin deposition; and 3) the active contacts used for ~ 6 years of effective bilateral DBS therapy lie in the zona incerta, just dorsal to the rostral STN. To the authors' knowledge, the period of STN DBS therapy herein described for Parkinson disease and subjected to postmortem analysis is the longest to date.

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