… effective stimulating electrodes in the human subthalamic nucleus on magnetic resonance imaging
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K EY W ORDS deep brain stimulation subthalamic nucleus Parkinson disease
neurosurgery magnetic resonance imaging T J. Neurosurg.
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J Neurosurg 97:1152–1166, 2002
Localization of clinically effective stimulating electrodes in the human subthalamic nucleus on magnetic resonance imaging
JEAN A. SAINT-CYR, PH.D., TASNUVA HOQUE, B.SC., LUIZ C. M. PEREIRA, M.D., JONATHAN O. DOSTROVSKY, PH.D., WILLIAM D. HUTCHISON, PH.D., DAVID J. MIKULIS, M.D., AVIVA ABOSCH, M.D., PH.D., ELSPETH SIME, R.N., ANTHONY E. LANG, M.D., AND ANDRES M. LOZANO, M.D., PH.D.
Departments of Surgery, Division of Neurosurgery; Physiology; Medicine, Division of Neurology; and Medical Imaging, University of Toronto and University Health Network, Toronto, Canada
Object. The authors sought to determine the location of deep brain stimulation (DBS) electrodes that were most effective in treating Parkinson disease (PD). Methods. Fifty-four DBS electrodes were localized in and adjacent to the subthalamic nucleus (STN) postoperatively by using magnetic resonance (MR) imaging in a series of 29 patients in whom electrodes were implanted for the treatment of medically refractory PD, and for whom quantitative clinical assessments were available both pre- and postoperatively. A novel MR imaging sequence was developed that optimized visualization of the STN. The coordinates of the tips of these electrodes were calculated three dimensionally and the results were normalized and corrected for individual differences by using intraoperative neurophysiological data (mean 5.13 mm caudal to the midcommissural point [MCP], 8.46 mm inferior to the anterior commissure–posterior commissure [AC–PC], and 10.2 mm lateral to the midline). Despite reported concerns about distortion on the MR image, reconstructions provided consistent data for the localization of electrodes. The neurosurgical procedures used, which were guided by combined neuroimaging and neurophysiological methods, resulted in the consistent placement of DBS electrodes in the subthalamus and mesencephalon such that the electrode contacts passed through the STN and dorsally adjacent fields of Forel (FF) and zona incerta (ZI). The mean location of the clinically effective contacts was in the anterodorsal STN (mean 1.62 mm posterior to the MCP, 2.47 mm inferior to the AC–PC, and 11.72 mm lateral to the midline). Clinically effective stimulation was most commonly directed at the anterodorsal STN, with the current spreading into the dorsally adjacent FF and ZI. Conclusions. The anatomical localization of clinically effective electrode contacts provided in this study yields useful information for the postoperative programming of DBS electrodes.
KEY WORDS • deep brain stimulation • subthalamic nucleus • Parkinson disease • neurosurgery • magnetic resonance imaging
HE neurosurgical treatment of selected patients with medically refractory PD has undergone a renaissance since the revival of Leksell’s pallidotomy procedure by Laitinen.51,59,91 Although many patients have been helped by pallidotomy, especially by the subsequent reduction in drug-induced dyskinesias, the implantation of DBS electrodes bilaterally, which was adapted from the experience of thalamic stimulation for relief of tremor, has gained considerable popularity.32,48,57,106 With advances in our understanding of the pathophysiology of PD, based on findings in
T
Abbreviations used in this paper: AC–PC = anterior commissure– posterior commissure; CT = computerized tomography; DBS = deep brain stimulation; FF = fields of Forel; GABA = -aminobutyric acid; MCP = midcommissural point; MPTP = 1-methyl-4-phenyl1,2,3,6-tetrahydropyridine; MR = magnetic resonance; PD = Parkinson disease; SD = standard deviation; SN = subthalamic nigra; SNc = SN pars compacta; SNr = SN pars reticulata; STN = subthalamic nucleus; UPDRS = Unified PD Rating Scale; ZI = zona incerta; 3D = three-dimensional.
animal models,108 the STN was reexplored as a potential target.48 It was observed that stereotactically guided lesions in the STN of the monkey MPTP model,9,18 as well as strokes involving the STN in patients with PD,90,103 resulted in a dramatic alleviation of symptoms. Although a number of patients have been reported who have been successfully treated with lesioning of the subthalamus (that is, of the STN and adjacent structures, particularly the FF and ZI),63 neurosurgeons remain concerned about the possibility of inducing ballismus or other adverse events.2,4,30,31 Thus, the placement of bilateral STN DBS electrodes has become the treatment of choice in many neurosurgery centers.14,32,52, 53,57,92 Experience with pallidal and thalamic DBS revealed that high-frequency stimulation appeared to mimic the effects of lesions, but in a modifiable and potentially reversible manner.15,58 In appropriately selected patients, the clinical outcome to date has been excellent, often resulting in a mean reduction of their medication by 50%62 and a significant alleviation of disabling symptoms.48,50 In relatively young patients the clinical benefit from STN DBS has been
J. Neurosurg. / Volume 97 / November, 2002
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