Direct Stereotactic MRI Location in the Globus Pallidus for Chronic Stimulation in Parkinson's Disease

Department of Neurology, University Hospital, Clermont-Ferrand, France.
Acta Neurochirurgica (Impact Factor: 1.77). 02/1999; 141(7):759-65; discussion 766. DOI: 10.1007/s007010050372
Source: PubMed


We evaluated the direct location in the globus pallidus (GP) under stereotactic MRI (sMRI) guidance in five parkinsonians treated with chronic deep brain stimulation (four bilaterally). The sMRI consisted of three orthogonal (horizontal, frontal, sagittal) sets of images obtained with a stereotactic frame and its localiser. The sMRI was coupled with ventriculography to compare the location with the classic indirect method based on commissural landmarks. The target was defined on T2-weighted slices in the anterior part of the medial GP, at the vertex of the nucleus. It was reached via one track with a semi-micro-electrode and step by step high frequency stimulation, then replaced by a quadripolar electrode once we located the site enabling the optimal clinical improvement. Stereotactic x-rays localised the final position of the electrode. A company software matched sMRI, ventriculography, and peroperative (perop) x-rays, with reference to the stereotactic location boxes. We analysed the effects of acute (perop) and chronic (six-month follow-up) stimulation of active plots (acplots), i.e. leading to optimal clinical improvement. Three distances with reference to the acplots were measured both on sMRI and ventriculography: the laterality from the median sagittal plane of the third ventricle; the anterior position from the midpoint of the intercommissural line (Icl), and the vertical position with regard to the Icl. We then compared the differences in measurements (n = 64) with the Bland and Altman method. The mean difference was 0.09 mm with 95% of the values between +/- 1 mm, but only the laterality had a statistically significant agreement (all the differences included between +/- two times the standard deviation of the mean). The acplots distances from the dorsal, ventral, and medial boundaries of GP (defined by manual surrounding on frontal and horizontal planes) were measured on sMRI. With one exception, the acplots were all included in the nucleus. The six-month acplots were located dorsally with reference to the perop ones. Clinical benefit at six-months follow-up showed results comparable to the literature. Direct location of GP target based on sMRI seems a simple and reliable method.

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    • "Crucial for the therapeutic effect is a proper electrode placement (Starr et al. 1998; Hariz 2000). For optimal target localization, CT and MRI provide anatomical information, whereas functional information is derived from presumed target sites by stimulation and recording techniques (Hutchison et al. 1998; Lemaire et al. 1999; Yoon & Munz 1999). High-frequency stimulation (HFS) at more than 100 Hz is administered to achieve optimal tremor suppression and to evoke characteristic side effects indicating positional errors ( Hassler et al. 1960; Gross et al. 2006). "
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    ABSTRACT: High-frequency test stimulation for tremor suppression is a standard procedure for functional target localization during deep brain stimulation. This method does not work in cases where tremor vanishes intraoperatively, for example, due to general anaesthesia or due to an insertional effect. To overcome this difficulty, we developed a stimulation technique that effectively evokes tremor in a well-defined and quantifiable manner. For this, we used patterned low-frequency stimulation (PLFS), i.e. brief high-frequency pulse trains administered at pulse rates similar to neurons' preferred burst frequency. Unlike periodic single-pulse stimulation, PLFS enables one to convey effective and considerably greater integral charge densities without violation of safety requirements. In a computational investigation of an oscillatory neuronal network temporarily rendered inactive, we found that PLFS evokes synchronized activity, phase locked to the stimulus. While a stronger increase in the amount of synchrony in the neuronal population requires higher stimulus intensities, the portion of synchronously active neurons nevertheless becomes strongly phase locked to PLFS already at weak stimulus intensities. The phase entrainment effect of PLFS turned out to be robust against variations in the stimulation frequency, whereas enhancement of synchrony required precisely tuned stimulation frequencies. We applied PLFS to a patient with spinocerebellar ataxia type 2 (SCA2) with pronounced tremor that disappeared intraoperatively under general anaesthesia. In accordance with our computational results, PLFS evoked tremor, phase locked to the stimulus. In particular, weak PLFS caused low-amplitude, but strongly phase-locked tremor. PLFS test stimulations provided the only functional information about target localization. Optimal target point selection was confirmed by excellent post-operative tremor suppression.
    Philosophical Transactions of The Royal Society A Mathematical Physical and Engineering Sciences 10/2008; 366(1880):3545-73. DOI:10.1098/rsta.2008.0104 · 2.15 Impact Factor
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    • "The classical stereotactic approach, historically based on ventriculography and stereotactic atlas [2][3], uses a proportional indirect method, i.e. the coordinates of the target are computed relatively to internal landmarks (AC/PC). A more recent approach, called direct targeting, relies on magnetic resonance imaging (MRI), which allows the direct visualization of the target[4]. "
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    ABSTRACT: Symptoms of Parkinson's disease can be relieved through deep brain stimulation. This neurosurgical technique relies on high precision positioning of electrodes in specific areas of the basal ganglia and the thalamus. In order to identify these anatomical targets, which are located deep within the brain, we developed a semi-automated method of image analysis, based on data fusion. Information provided by both anatomical magnetic resonance images and expert knowledge is managed in a common possibilistic frame, using a fuzzy logic approach. More specifically, a graph-based virtual atlas modeling theoretical anatomical knowledge is matched to the image data from each patient, through a research algorithm (or strategy) which simultaneously computes an estimation of the location of every structures, thus assisting the neurosurgeon in defining the optimal target. The method was tested on 10 images, with promising results. Location and segmentation results were statistically assessed, opening perspectives for enhancements.
    Conference proceedings: ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference 02/2006; 1:144-7. DOI:10.1109/IEMBS.2006.260195
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    ABSTRACT: Studying the clinical effects induced by electrical stimulation of the subthalamic nucleus (STN) area in a parkinsonian patient under local anesthesia is a mandatory step to determine the precise location of the final chronic electrode. Using multiple microelectrodes, preferably in a concentric parallel array allows a precise mapping of the STN region. The most reliable features to determine the suitable target are stimulation-induced dyskinesias and rigidity decrease at a low intensity without adverse effects or only at far higher intensities. New skills are needed to assess all stimulation-induced effects and interpret them in anatomo-functional terms. © 2002 Movement Disorder Society
    Movement Disorders 02/2002; 17(S3):S155 - S161. DOI:10.1002/mds.10158 · 5.68 Impact Factor
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