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Optimization and comparative evaluation of nonlinear deformation algorithms for atlas-based segmentation of DBS target nuclei

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Nonlinear registration of individual brain MRI scans to standard brain templates is common practice in neu- roimaging and multiple registration algorithms have been developed and refined over the last 20 years. How- ever, little has been done to quantitatively compare the available algorithms and much of that work has ex- clusively focused on cortical structures given their importance in the fMRI literature. In contrast, for clinical applications such as functional neurosurgery and deep brain stimulation (DBS), proper alignment of subcorti- cal structures between template and individual space is important. This allows for atlas-based segmentations of anatomical DBS targets such as the subthalamic nucleus (STN) and internal pallidum (GPi). Here, we systematically evaluated the performance of six modern and established algorithms on subcortical normalization and segmentation results by calculating over 11,000 nonlinear warps in over 100 subjects. For each algorithm, we evaluated its performance using T1-or T2-weighted acquisitions alone or a combination of T1-, T2-and PD-weighted acquisitions in parallel. Furthermore, we present optimized parameters for the best performing algorithms. We tested each algorithm on two datasets, a state-of-the-art MRI cohort of young sub- jects and a cohort of subjects age- and MR-quality-matched to a typical DBS Parkinson's Disease cohort. Our final pipeline is able to segment DBS targets with precision comparable to manual expert segmentations in both co- horts. Although the present study focuses on the two prominent DBS targets, STN and GPi, these methods may extend to other small subcortical structures like thalamic nuclei or the nucleus accumbens.
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Running title: Evaluation of normalization methods for subcortical segmentation
Optimization and comparative evaluation of nonlinear
deformation algorithms for atlas-based segmentation of
DBS target nuclei
Siobhan Ewert1,2, Andreas Horn1, Francisca Finkel2,3, Ningfei Li1,4, Andrea A. Kühn1,
Todd M. Herrington2
1) Charité – University Medicine Berlin, Department of Neurology, Movement
Disorders and Neuromodulation Unit, Berlin, Germany.
2) Department of Neurology, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA
3) Program in Behavioral Neuroscience, Northeastern University, Boston,
MA, USA
4) Institute of Software Engineering and Theoretical Computer Science,
Neural Information Processing Group, Technische Universität Berlin, Germany
Keywords: Manual segmentation, Automated segmentation, Atlas-based
segmentation, Subcortical normalization, spatial image deformation, DBS.
Corresponding Author
Todd Herrington: THERRINGTON@mgh.harvard.edu!
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Running title: Evaluation of normalization methods for subcortical segmentation
Highlights:
We compared six modern nonlinear deformation algorithms to assess
performance for subcortical structures with specific focus on the
segmentation of two common deep brain stimulation (DBS) targets:
subthalamic nucleus (STN) and globus pallidus internus (GPi).
Parameters of best performing algorithms were optimized to maximize
precision of subcortical deformations
These optimized pipelines are able to segment DBS targets with precision
comparable to manual expert segmentations
The optimized pipelines have been made available to the scientific
community through the open source toolbox Lead-DBS
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Running title: Evaluation of normalization methods for subcortical segmentation
Abstract
Nonlinear registration of individual brain MRI scans to standard brain templates is
common practice in neuroimaging and multiple registration algorithms have been
developed and refined over the last 20 years. However, little has been done to
quantitatively compare the available algorithms and much of that work has exclusively
focused on cortical structures given their importance in the fMRI literature. In contrast, for
clinical applications such as functional neurosurgery and deep brain stimulation (DBS),
proper alignment of subcortical structures between template and individual space is
important. This allows for atlas-based segmentations of anatomical DBS targets such as
the subthalamic nucleus (STN) and internal pallidum (GPi).
Here, we systematically evaluated the performance of six modern and established
algorithms on subcortical normalization and segmentation results by calculating over
11,000 nonlinear warps in over 100 subjects. For each algorithm, we evaluated its
performance using T1- or T2-weighted acquisitions alone or a combination of T1-, T2- and
PD-weighted acquisitions in parallel. Furthermore, we present optimized parameters for
the best performing algorithms. We tested each algorithm on two datasets, a state-of-the-
art MRI cohort of young subjects and a cohort of subjects age- and MR-quality-matched to
a typical DBS Parkinson’s Disease cohort. Our final pipeline is able to segment DBS
targets with precision comparable to manual expert segmentations in both cohorts.
Although the present study focuses on the two prominent DBS targets, STN and GPi,
these methods may extend to other small subcortical structures like thalamic nuclei or the
nucleus accumbens. !
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Running title: Evaluation of normalization methods for subcortical segmentation
Abbreviations
DBS = Deep brain stimulation
FLAIR = Fluid attenuated inversion recovery
HCP = Human Connectome Project
PD = Parkinson’s Disease
PC = Pseudo-clinical cohort (= age- and MR-quality-matched IXI dataset)
QSM = Quantitative Susceptibility Mapping
RN = Red nucleus
SD = mean absolute surface distance in mm
SN = Substantia nigra
SNR = Signal-to-Noise-Ratio
STN = Subthalamic nucleus
Std = Standard deviation
TPM = Tissue probability maps
YC = Young cohort (HCP dataset)
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Running title: Evaluation of normalization methods for subcortical segmentation
Introduction
Translating single-subject imaging into common space such as the MNI space is a
core concept in the field of brain mapping (Evans et al., 2012). It allows for comparison of
structural and functional MRI findings across brains, cohorts and research centers.
Increasingly these techniques are being applied in clinical contexts including stroke (Fox et
al., 2014) and deep brain stimulation (DBS) (Horn et al., 2017a; 2017b). In the latter,
subcortical atlases allow for delineation of DBS targets such as the subthalamic nucleus
(STN) and internal part of the globus pallidus (GPi) that are imperfectly resolved on
standard clinical MRI (Ewert et al., 2017). By transforming single-subject data into a
common reference frame such as MNI space, one can leverage the considerable brain
imaging data available in public repositories (Horn et al., 2017a; Klein et al., 2009; Crivello
et al., 2002). Example subcortical atlases include the probabilistic ATAG atlas (Keuken et
al., 2014), the 7T based “ultra-high field atlas for DBS planning” (Wang et al., 2016) and
the DISTAL DBS atlas (Ewert et al., 2017). Similarly, connectomic resources such as
normative structural and functional connectomes in MNI space are now available (Horn
and Blankenburg, 2016; Horn et al., 2014) and have been used to explore the functional
and structural networks targeted by DBS (Horn et al., 2017b; 2017a). Critical to this
approach is the accurate transformation of single-subject imaging into the atlas space (or
vice versa).
In the context of DBS, we often want to determine the spatial relationship between
the implanted electrode and its specific target. This is also important for studies that
assess electrode localizations across patients to identify spatial correlates of treatment
outcomes (Horn et al., 2017b; Neumann et al., 2017; Israel and Bergman, 2016; Welter et
al., 2014; Tisch et al., 2007). Another application for transforming atlas information to
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Running title: Evaluation of normalization methods for subcortical segmentation
single-subject imaging is the segmentation of target nuclei on preoperative MRI
acquisitions for DBS surgical planning.
Such patient-to-template or template-to-patient registrations are termed “atlas-
based segmentation” and are important because manual segmentations of DBS related
structures is highly time consuming, requires expert anatomical knowledge (Forstmann et
al., 2017; Zwirner et al., 2016; Visser et al., 2016b; Chakravarty et al., 2013) and may not
be straightforward on clinical MRI data given insufficient signal-to-noise ratio or resolution.
Thus, the automated segmentation of STN and GP has been a field of vital and ongoing
work with innovative contributions by multiple research groups (Garzón et al., 2017; Visser
et al., 2016b; 2016a; Chakravarty et al., 2013; Haegelen et al., 2012; Helms et al., 2009;
Lim et al., 2013; Villegas et al., 2009). In addition, many more general methods facilitating
imaging co-registration have been developed over the last 20 years, primarily within the
field of brain imaging (Ashburner, 2007; Ashburner and Friston, 2011; Andersson et al.,
2010, Avants et al., 2010; Schonecker et al., 2009).
Despite the many developments in this field, comparative studies evaluating the
alignment of subcortical structures in image registration are lacking, perhaps due to the
focus on cortical structures in support of the fMRI literature (Glasser et al., 2016). In 2009,
Klein and colleagues published an influential study comparing algorithm performance for
cortical structures (Klein et al., 2009). However, only a few, coarsely defined subcortical
structures were assessed. Moreover, since 2009 the algorithms studied have been
improved substantially.
Here, we evaluated and optimized the preset parameters of six commonly used
deformation algorithms. Multiple parameters were evaluated for most algorithms. Each
algorithm, except for one, was evaluated for results of both multi- and mono-spectral
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Running title: Evaluation of normalization methods for subcortical segmentation
datasets. Specifically, we assessed the performance of each algorithm using T1- or T2-
weighted imaging alone versus a combination of T1-, T2- and Proton Density weighted
MRI. In total, we estimated over 11,000 deformations from 103 manually labeled subject
brains to template space. Results were compared to manual expert segmentations.
Accuracy of normalizations was estimated in a high-quality dataset consisting of healthy
subjects acquired in the Human Connectome Project. These MR scans exhibit a high
signal-to-noise ratio and were acquired on specialized hardware, representing an as-good-
as-it-gets example dataset for 3T data. Second, we estimated results on data from the IXI
project which resembles MR image quality commonly acquired on 1.5 or 3T magnets.
These MRIs represent a more typical example of what is acquired in routine clinical
practice or when the focus is not on specialized structural imaging. In addition, the IXI data
set includes T1, T2 and PD acquisitions, allowing us to assess the performance of multi-
vs. monospectral normalizations.
The present study was done with a particular focus on the two most common DBS
targets, STN and GPi, though a translation to other small subcortical structures such as
thalamic nuclei or the nucleus accumbens may potentially be inferred. To facilitate the
broadest utility of these results to the scientific community, we have distributed all
parameters and Tissue Probability Maps (TPM) and include practical information on the
required computational processing times required for each algorithm presented.
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Running title: Evaluation of normalization methods for subcortical segmentation
Methods
Subjects and data
Two datasets were analyzed, a high quality 3T data set in young subjects (“Young
Cohort”; YC from hereon; image resolution 0.7mm3 isometric; age range 22 - 35 yrs, two
subjects 36+ yrs; mean age 28,7 yrs, std=3,42 yrs; F:M = 49:24) and a data set
resembling clinically acquired MRIs for DBS patients (“Pseudo-Clinical”; PC; image
resolution 0.94x0.94x1mm3; age range 55 - 70 yrs, mean age 62,9 yrs, std=4,2 yrs; F:M =
17:13; for an exact list of YC- and PC-subjects please see section “Lists of segmented
subjects” in supplementary material). 3T data was obtained from The Human Connectome
Project (HCP) (https://db.humanconnectome.org/, ‘WU-Minn HCP Data - 900 subjects’;
Fischl, 2012; Jenkinson et al., 2002; Marcus, 2018; Van Essen et al., 2012). 73 unrelated
subjects with sufficient image contrast for manual segmentation were selected. For each
subject, both structural image modalities, T1-weighted (T1w) and T2-weighted (T2w)
images were selected. Minimal preprocessing steps had been done within the HCP
standard preprocessing workflow and included correction of gradient nonlinearity and field
map distortion, removal of spatial artifacts, within-subject cross-modal registration and
aligning the subject’s native volume header to MNI space using a rigid body transform
estimated by the FLIRT tool (FSL 5.0, Jenkinson et al., 2012). For details on the HCP
preprocessing pipeline please see (Glasser et al., 2013).
To address how accurate automated segmentation algorithms would perform on
clinical data (sometimes acquired on 1.5T with low signal to noise ratio and including older
patients), a “typical clinical” dataset was obtained from the IXI project (http://brain-
development.org/ixi-dataset/). A sub-cohort of 30 subjects aged between 55-70 years
(age-matching a typical age of Parkinson’s disease (PD) patients undergoing DBS
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Running title: Evaluation of normalization methods for subcortical segmentation
surgery), whose imaging was free of gross motion artifact were randomly selected for this
study. These subjects were scanned on either 1.5T or 3T MR hardware and provided T1w,
T2w and Proton-Density-weighted images. In contrast to the YC, these images were
neither co-registered cross-modally within-subject nor rigidly aligned to MNI space. Cross-
modal, within-subject registration was performed using SPM12.
Additional details on the quality of the data used and a list of specific subjects is
available in the supplementary materials.
Manual segmentation
In total, left and right GPi and left and right STN of 103 brains were manually
segmented (73 YC and 30 PC). Manual segmentations were performed following a
specified and published protocol (Ewert et al., 2017) in 3DSlicer (https://www.slicer.org/)
(see also “Detailed Segmentation Protocol” in supplementary material). Manual
segmentations were carried out by either one of two raters (S.E. and F.F.) with overall 41%
of HCP and 33% of IXI images segmented by both raters to estimate inter-rater reliability
(see supplementary materials for details). The anatomical outlines of the segmented
structures were defined with reference to neuroanatomical atlases and in-house acquired
high resolution post-mortem 7T MRI scans that showed the target structures in detail
(Edlow et al., 2018; Ding et al., 2016; Mai et al., 2015; Massey et al., 2012; Naidich et al.,
2009).
Measures of inter-rater agreement
Inter-rater agreement was determined for each dataset by calculating both Dice
coefficient (Dice, 1945) and the mean absolute surface distance (SD) (Wang et al., 2016)
which measures the mean euclidean distance between two surfaces. All analyses were
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Running title: Evaluation of normalization methods for subcortical segmentation
performed using MATLAB 2015b (The MathWorks, Inc., Natick, Massachusetts, United
States).
Normalization and Automatic Segmentation
The MNI ICBM 152 NLIN 2009b template was used (Fonov et al., 2011). Native
subject volumes were nonlinearly deformed into template space (normalization) using
established algorithms included in the Lead-DBS v2.1.0 software package (www.lead-
dbs.org; (Horn and Kühn, 2015)). Using these algorithms, deformation fields that project
patient volumes into template space were estimated, inverted and applied to a precise
definition of target structures (STN and GPi) in the DISTAL atlas in template space (Ewert
et al., 2017). This process will subsequently be referred to as “atlas-based segmentation”.
The DISTAL atlas consists of a precise manual segmentation of the subthalamic
nucleus and internal pallidum. This segmentation was performed on a high definition MNI
template (ICBM 2009b nlin asym, Fonov et al., 2011) that is available in multiple
modalities. These were used to generate an automatic pre-segmentation that was used
alongside each individual spectra (T1, T2, etc.) to segment the structures of interest.
To assess the accuracy of each normalization, the atlas-based (automatic)
segmentations were compared to manual segmentations of the corresponding nucleus in
native space (Figure 1). Agreement between atlas-based and manual segmentations was
again assessed by calculating the Dice coefficient and mean surface distance. Nucleus
volumes (in mm3) for automatic and manual segmentations were correlated by correlating
the sum of voxel volumes of the respective nuclei.
We practically optimized parameters and compared subcortical alignment for the
following nonlinear image registration tools: the SyN (Avants et al., 2010) and BSplineSyN
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Running title: Evaluation of normalization methods for subcortical segmentation
(Tustison, 2013) symmetric diffeomorphic image registration methods implemented in
Advanced Normalization Tools 2.2.0 (http://stnava.github.io/ANTs/), three methods
implemented in SPM12 (7219) software (http://www.fil.ion.ucl.ac.uk/spm/software/spm12/)
(“New Segment” (Ashburner and Friston, 2005), “DARTEL” (Ashburner, 2007) and
“SHOOT”, (Ashburner and Friston, 2011), FNIRT as implemented in FSL 5.0.10
(Andersson et al., 2010), and a three-step linear method that had been specifically
developed to register deep brain stimulation electrodes to MNI space (Schonecker et al.,
2009). Table 1 gives a summary of each method, and in the following sections we describe
in more detail how we optimized the input parameters of our tested algorithms.
For ANTs we evaluated ANTs SyN (Avants et al., 2011) and ANTs BSplineSyN
(Tustison, 2013), each with multiple different presets and with uni- versus multimodal
datasets (T1 vs. T1 & T2 vs. T2-weighted MRI). We evaluated different degrees of gradient
steps, shrinking factors, penalties for high frequency image deformations, convergence
parameters, winsorizing and smoothing sigmas to produce three levels of allowable
deformation field strength termed low, mid and high variance. For the winning method
(ANTs SyN with the preset “Low Variance”), we additionally evaluated another step of
subcortical refine similar to the one described in (Schonecker et al., 2015). Here, as a last
step after the global non-linear alignment of the whole brain, a subsequent warp was
applied guided by a subcortical mask that focused on the basal ganglia. The final
optimized parameters for registration of subcortical structures evaluated in the present
study is the ANTs-based SyN approach with subcortical refinement termed “Effective (Low
Variance)” which is now the default normalization method of Lead-DBS software v.2.1.6.
Specific parameters of this method and the principal competing presets are published
online (https://github.com/leaddbs/leaddbs/blob/master/ext_libs/ANTs/presets/). The mask
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Running title: Evaluation of normalization methods for subcortical segmentation
used for the final subcortical refinement step is also supplied with Lead-DBS software and
is shown in Figure S1 relative to the T1 ICBM 2009b nlin asym template.
For the SPM methods we evaluated the accuracy of subcortical image registration
using different tissue priors. The SPM methods use Tissue Probability Maps (TPMs) as
priors for their image segmentation and subsequent registration with the segmented
template image. Critical to this method is a proper definition of subcortical target structures
in both subject and template TPM. We tested the results of two other TPMs against the
original SPM TPM which was derived from the same IXI dataset (http://brain-
development.org/ixi-dataset/) that formed our clinically age- and SNR-matched dataset,
the PC (http://www.fil.ion.ucl.ac.uk/spm/software/spm12/SPM12_Release_Notes.pdf). The
second TPM tested was the one created by (Lorio et al., 2016). To create the third TPM,
we adopted the approach described in (Lorio et al., 2016) and created a specialized
template TPM with a refined definition of our subcortical target structures. Using the Lorio-
template as a starting point, we used SPM New Segment to segment our target template.
Subsequently, we used these segmentation as priors for SPM New Segment and our
evaluated two cohorts. This TPM is currently implemented in Lead-DBS and can be
downloaded at www.lead-dbs.org.
For the final, linear image registration algorithm, we used ANTs linear as registration
method with the default input parameters. To improve the accuracy of this method we did,
however, adapt the two-step approach described in (Schonecker et al., 2009). The first
step computes a global alignment between the individual and the target brain. The second
step focuses on the subcortex using a mask that focuses on the basal ganglia and
brainstem (Figure S1).
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Running title: Evaluation of normalization methods for subcortical segmentation
ANTs and SPM methods were the most accurate registration methods in a previous
comparative study that focused on cortical structures (Klein et al., 2009). These two
pipelines also allow for multispectral warps, which in theory may help compensate for
deficiencies of individual MRI sequences. For example, the STN is not visible on T1, which
is often the volume with best spatial resolution, so a combined warp that uses information
from both T1- and T2-weighted volumes appears sensible. The best performing ANTs
preset with an additional step of subcortical refine similar to the one described in
(Schonecker et al., 2015) and the best performing TPM (for the SPM methods) were then
subjected to detailed comparison and assessment.
Comparison of results
Similarity measures between manual and automatic segmentations for each
method were analyzed using one-way ANOVA analyses. Pairwise multiple comparison
post-hoc tests between each pair of approaches were estimated using Tukey's Honest
Significant Difference procedure (as is default in Matlab’s anova1 and multcompare
functions).!
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Running title: Evaluation of normalization methods for subcortical segmentation
Results
For each algorithm tested, we compared the accuracy of the atlas-based automated
segmentation compared to the manually segmented target by means of a Dice coefficient.
We first assessed the performance of two ANTs nonlinear warping algorithms (Syn and
BSplineSyN) each with different degrees of gradient steps, shrinking factors, penalties for
high frequency image deformations, convergence parameters, winsorizing and smoothing
sigmas to produce three levels of allowable deformation field strength termed low, mid
and high variance. The performance of each algorithm is shown in Figure 2 by means of
violin plots showing the distribution of Dice coefficients. The best performing algorithm was
ANTs Syn Low Variance with subcortical refinement, using a T1 + T2-weighted multimodal
imaging data set. This ANTs Syn preset penalizes high-frequency image deformations and
includes an additional final normalization step using a subcortical mask.
We turned next to the SPM methods, New Segment, SHOOT and DARTEL. The
SPM methods use Tissue Probability Maps (TPMs) as priors for the image segmentation
and subsequent registration with the segmented template image. Critical to this method is
a proper definition of subcortical target structures in both subject and template TPM. We
evaluated the performance of the original SPM TPM (which was derived from the IXI
dataset), against the TPM described by Lorio (Lorio et al., 2016) and a novel TPM
implemented within Lead-DBS. Figure 3 shows the automated segmentation performance
of SPM New Segment Results using each of the three TPMs. For the YC, we see a slight
improvement of image registration accuracy for the Lead-DBS TPM. In contrast, in the PC
the original SPM TPM performed slightly better than the Lead-DBS template, perhaps
owing to it having been developed on the IXI dataset from which the PC cohort was
selected. The Lead-DBS TPM was used in the subsequent main analysis.
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Running title: Evaluation of normalization methods for subcortical segmentation
We then compared these optimized algorithms to a subcortically focused linear
coregistration and FNIRT as implemented in FSL. The comparative performance of all
methods is summarized in Tables 2a+b and Figures 4a+b. Results are shown separately
for YC (Figure 4a and Table 2a) and PC (Figure 4b and Table 2b). Of all the methods
compared, SPM Segment and ANTs SyN performed best yielding an accurate
segmentation with Dice coefficients typical of inter-rater reliability. Overall results for YC
(median Dice) from lowest to highest are 0.56 (Linear); 0.67 (SPM SHOOT); 0.68 (SPM
DARTEL); 0.70 (FNIRT); 0.73 (SPM Segment); 0.74 (ANTs SyN); 0.78 (Inter-Rater).
Overall results for PC (median Dice) from lowest to highest are 0.57 (Linear); 0.57 (SPM
DARTEL); 0.58 (FNIRT); 0.59 (SPM SHOOT); 0.64 (SPM Segment); 0.66 (Inter-Rater);
0.68 (ANTs SyN). Representative examples of the two best and two worst performing
subjects for each algorithm and each data set are shown in Figures S2a and Figures S2b.
Figures 5a+b and Tables 3a+b show a more detailed analysis for the two best
performing methods, SPM Segment and ANTs SyN. Here, in addition to the Dice
coefficient, the mean surface distance (SD) as well as volume correlations between atlas-
based and manual segmentation for each subject are shown. Results are displayed for
STN and GPi separately. Figure 5a and Table 3a show the results for the YC, while Figure
5b and Table 3b show the same results for the PC. Notably, the Dice coefficients and SD
achieved with both methods, SPM Segment and ANTs SyN, almost reached inter-rater
level accuracy for the YC. For the PC there was no significant difference in accuracy
between inter-rater and atlas-based segmentations.
Specifically, in the YC for the STN, inter-rater agreement by means of SD was not
significantly better than ANTs SyN (median SD 0.41mm vs. 0.38mm) indicating a very high
normalization accuracy for this method in the subcortical region of the STN (Figure 5a and
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Running title: Evaluation of normalization methods for subcortical segmentation
Table 3a). For the GPi, SPM Segment performed slightly better than ANTs SyN showing no
significant difference between inter-rater agreement by means of Dice or SD (p > 0.1). In
fact, for the mean SD of GPi segmentations no method proved significantly different than
inter-rater mean SD (p > 0.8). To further compare the results of atlas-based and manual
segmentation in the YC, we compared the volumes of the segmented nuclei (right panels
in Figure 5a+b). For both methods and nuclei we see a small but significant correlation
between manual and automated segmentation volumes. Atlas-based segmentations by
SPM Segment and ANTs SyN are reasonable in size (mean volume STN and GPi by ANTs
SyN: 148mm3 and 406mm3; SPM Segment: 119mm3 and 377mm3). For additional details
of volumes resulting from atlas-based segmentations compared to volumes of manual
segmentations in the YC and PC please see lower sections of Tables 3a+b.
The median Dice coefficient for inter-rater agreement in the YC for subjects
segmented by both raters (S.E and F. F.) was 0.76 ± 0.09 (standard deviation) for STN and
0.80 ± 0.05 for GPi. We found no significant effect of hemisphere on inter-rater Dice
coefficients (p > 0.1). Median surface distance (SD) was 0.41 mm ± 0.20 for STN and 0.45
mm ± 0.14 for GPi, corresponding to less than one voxel, again without significant effect
of hemisphere (p > 0.1). Inter-rater agreement was lower in the PC. Dice coefficients for
the PC were 0.66 ± 0.10 STN and 0.65 ± 0.06 for GPi. Median SD was 0.64 mm ± 0.25
for STN and 0.82 mm ± 0.16 for GPi. Again, no significant effect of hemisphere was found
in any of these metrics (p > 0.2). Tables 3a and 3b present inter-rater results in detail.
In the YC, segmentation mean volumes of GPi were 359mm3 ± 50 (standard
deviation), (range 231 - 473mm3) and of STN 120mm3 ± 20 (range 68 - 168mm3). For
volumes of the GPi, there was no significant difference between left and right hemisphere
(p = 0.49) and volumes correlated significantly between hemispheres (R = 0.605, p <
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Running title: Evaluation of normalization methods for subcortical segmentation
0.001). As previously reported in the literature (Shen and Gao, 2009; Nowinski et al.,
2005), a significant difference between volumes of left and right STN was found (p =
0.031; mean volume for left STN = 122mm3, std = 22, mean volume for right STN =
118mm3, std = 18). Segmented volumes of GPi and STN within the same subject also
correlated significantly (R = 0.326, p < 0.001). In the PC, both STN and GPi volumes were
significantly smaller compared to the YC (p < 0.05) which is likely attributable to a
combination of lower data resolution and lower subcortical contrast (mean volumes GPi:
324mm3 ± 62 , range 157 - 434mm3; STN: 112mm3 ± 19 , range 74 - 154mm3). Again,
volumes correlated significantly across hemispheres (STN: R = 0.525, p < 0.005; GPi: R =
0.376, p < 0.05). However, no significant difference in volume was found between
hemispheres (p = 0.07 and p = 0.67 respectively). Furthermore, no significant correlation
could be found for segmented volumes of GPi and STN within the same subject (R =
0.132, p = 0.315).
The manual segmentation of the PC dataset was more challenging due to the lower
subcortical contrast and image resolution. This is reflected in the lower Dice coefficient
between the manual segmentations of YC and PC (median Dice for both nuclei 0.78 and
0.66 respectively). Nevertheless, automated segmentation performed well (Figure 3b and
Table 3b). For the PC, the performance of both methods (SPM Segment and ANTs SyN)
was statistically indistinguishable from inter-rater agreement for Dice coefficient and SD for
both nuclei (inter-rater median Dice STN and GPi: 0.66 and 0.65; median SD STN and GPi
in mm: 0.64 and 0.82). SPM Segment performed slightly better for SD than ANTs SyN
(median SD STN and GPi Segment vs. ANTs SyN in mm: 0.52 and 0.73 vs. 0.61 and
0.75), whereas ANTs SyN performed slightly but significantly better as measured by Dice
coefficient (median Dice STN and GPi for SPM Segment vs. ANTs SyN: 0.62 and 0.68 vs.
0.67 and 0.71). For additional details please see Table 3b. Due to a lower number of
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Running title: Evaluation of normalization methods for subcortical segmentation
segmented brains in the PC versus the YC cohorts (30 vs. 73 brains), we have lower
statistical power. Only SPM Segment for the GPi showed a statistically significant
correlation between manual and automatic segmented volumes. This may be due to the
reduced SNR of the PC-dataset and increased variability of manual segmentation
volumes. Still, atlas-based segmentation volumes in the PC cohort remain reasonable
(mean volume STN and GPi by ANTs SyN: 118 and 380mm3; SPM Segment: 112 and
357mm3).
Computational time per method
Computational time and memory requirements are important practical
considerations when implementing these methods in a research or clinical workflow. Table
4 presents an estimate of required computation time for each method based on commonly
available computational resources. The MacBook Pro (left row) had the following
specifications: Memory 16 GB 1867 MHz DDR3; Processor 2,9 GHz Intel® Core™ i5. The
desktop PC (right row) was better equipped: Memory 64 GB; Processor Intel® Core™
i7-7700K CPU @ 4.20 Ghz × 8. The computations are based on a test subjects with
multimodal input data consisting of a T1- and T2-weighted MRI. SPM Segment proved to
be the fastest evaluated algorithm. ANTs SyN with the additional refinement of subcortical
alignment was substantially slower. The processing times were primarily dependent on
CPU throughput and were not limited by RAM in either of these configurations.#
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Discussion
We draw three main conclusions from this study. First, we evaluated six commonly
used nonlinear deformation algorithms for human brain MRI and identified two methods
that perform superiorly. We optimized their parameters and underlying data for alignment
of subcortical structures with high precision. Second, we report that the accuracy of these
optimized atlas-based segmentations are similar to inter-rater accuracy of expert manual
raters, especially for data with lower signal to noise ratio as is common in clinical practice.
These results also allow us to quantify the amount of error introduced when comparing
subcortical results – such as DBS electrode placements $across patients in standard
space. Third, we demonstrate that multimodal image registration is more accurate than
unimodal image registration for subcortical structures. This motivates the preoperative
acquisition of multispectral data in patients undergoing functional neurosurgery.
We compared six established, openly available nonlinear deformation algorithms
from four software suites with a focus on subcortical structures. Similar to prior studies
focused on cortical segmentations, this was done by computing the overlap of automated
segmentations with manual segmentations (Klein et al., 2009) and comparing accuracy of
this overlap to the inter-rater accuracy of two independent manual raters. Dice coefficients
of inter-rater YC-STN segmentations (mean 0.75) indicate a good inter-rater agreement
and are comparable with inter- and intra-rater STN segmentations reported by other
groups (Garzón et al., 2017; Lorio et al., 2016; Wang et al., 2016; de Hollander et al.,
2014; Keuken et al., 2014). For the GPi the mean Dice coefficient was 0.79 which is also
comparable to previously reported results (Makowski et al., 2017; Lorio et al., 2016; Wang
et al., 2016; Keuken et al., 2014). Both results indicate sufficient overlap to establish a
valid ground truth from which to assess automated segmentation.
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Running title: Evaluation of normalization methods for subcortical segmentation
Similar to prior results in the cortical domain, subcortically optimized ANTs and SPM
implementations performed the best. However, there were some notable differences. First,
within SPM, the oldest of the evaluated methods, the Unified Segmentation algorithm
(Ashburner and Friston, 2005) yielded slightly superior results in comparison to newer
implementations DARTEL and SHOOT (Ashburner, 2007; Ashburner and Friston, 2011)
although these outperformed the Unified Segmentation approach in previous studies with
a cortical focus (Klein et al., 2009). There are three potential explanations. First, DARTEL
and SHOOT were created and optimized for precision in the cortex (Ashburner and
Friston, 2011) and have primarily been utilized for fMRI. Second, the algorithms build upon
subject-specific Tissue Probability Maps (TPMs) that result from the preceding Unified
Segmentation step. They may only improve results if a proper definition of target structures
in both subject and template TPM is given. In contrast to cortical gyri, for small subcortical
structures this may not always be the case. To account for this, we did adopt (Lorio et al.,
2016), as well as create a specialized template TPM with refined definition of these
structures which did improve results (Figure 3). Third, DARTEL and SHOOT were
designed to perform group-wise registrations. Here, they were evaluated for pair-wise
registrations since i) this represents a more suitable use-case for clinical neuroimaging
and ii) in a prior study, group-wise and pair-wise results of DARTEL were reported not to
differ (Klein et al., 2009). A second difference was that the ANTs based SyN approach
outperformed the BSplineSyN approach. Again, BSplineSyN is the newer algorithm that
had outperformed SyN for cortical normalization when it was introduced (Tustison, 2013).
In summary, models with low variance in general outperformed models with high variance.
One reason for this may be that small structures in the subcortex do not exhibit high image
contrast and best results may be achieved by aligning surrounding anatomical structures
instead of the nuclei themselves.
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Running title: Evaluation of normalization methods for subcortical segmentation
The choice of normalization technique is important
To date, there is no accepted standard for performing normalization of small
subcortical nuclei. Figure 6 demonstrates how variable normalization results can be
depending on the method chosen. Here, we show the result of three example methods
(ANTs SyN, SPM SHOOT and ANTs BSplineSyN) that were applied to multi-modally warp
a single patient volume to MNI space. The patient had bilateral electrode implanted in the
GPi. The ground truth of the electrode position can be seen on the native patient image
(Figure 6A). Three-dimensional reconstructions of DBS electrodes, as shown in B-D, may
form a false sense of certainty when presented in isolation without the raw data. This is
especially true for fully-automated platforms and highlights the importance of incorporating
reports on registration accuracy or an interface for manual confirmation (Husch et al.,
2018a; 2018b; D'Haese et al., 2010). However, depending on the chosen method, results
differed meaningfully. The exemplary results of Figure 6 underline the relevance of our
findings, the importance of choosing the right method, and emphasize the importance of
manual performance checks even for our best performing algorithms.
No registration pair in the sample analyzed here failed in terms of a gross
misalignment between subject and template. However, there was variability in registration
quality, in particular with the three-step linear approach. The reason for generally high
robustness could be that HCP subject data had been linearly prealigned to the MNI space
by the HCP team and subjects off the IXI dataset were scanned with rough alignment to
the AC/PC line. The two best and two worst performing automated segmentation results
for each data set and method are shown in Supplementary Figures S2a and S2b.
Results of atlas-based segmentations compared with other automated
segmentation methods
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Running title: Evaluation of normalization methods for subcortical segmentation
Others have proposed alternative strategies of automatic segmentation of DBS
structures (Garzón et al., 2017; Visser et al., 2016b; 2016a; Xiao et al., 2014; Chakravarty
et al., 2013; Haegelen et al., 2012). In a recent paper, Garzón et al. use a new automated
segmentation method for the midbrain target regions STN, SN and RN. Their algorithm
constructs a map of spatial priors based on a training set of manual labels nonlinearly
registered to the midbrain. For the STN, they reported Dice scores of 0.66 for 3T QSM-,
0.57 for R2*- and 0.59 for FLAIR-weighted MRI 0.59.
Visser et al. recently introduced a new method called MIST (Multimodal Image
Segmentation Tool) which uses multiple image modalities simultaneously while using one
single reference segmentation for the initialization. On 7T MRI data they reached median
Dice scores for their automated segmentation of around 0.60 for the STN (Visser et al.,
2016b). On a different 1.5T clinical dataset they reached Dice scores for the whole globus
pallidus of around 0.75 and median mean mesh distances (compare to our mean surface
distances) of around 0.8mm (Visser et al., 2016a).
Chakravarty et al. presented a multi-atlas-based approach that was extended by the
use of an automatically generated set of templates derived from different brains
(Chakravarty et al., 2013). This “template layer” introduces an additional level of redundant
registrations, in a first step warping the atlas brain(s) to all template brains and in a second
step all of the template brains to the individual, to-be-segmented brain. This results in
multiple versions of automatic segmentations in the individual brain that are then
combined in a final segmentation. In theory this will distribute and thus eliminate errors
from single warps due to registration and resampling errors. Using this method they
reported a Dice coefficient of 0.75 for the whole globus pallidus.
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Running title: Evaluation of normalization methods for subcortical segmentation
In the young cohort for our best-performing method (ANTs SyN with preset “Low
Variance with Subcortical Refine”) we were able to reach a mean Dice score for STN and
GPi of 0.72 and 0.75 respectively and a mean SD of 0.38mm and 0.49mm. This approach
performs similarly to the best of the previously reported methods (Husch et al., 2018b;
Garzón et al., 2017; Visser et al., 2016b; 2016a; Chakravarty et al., 2013; Haegelen et al.,
2012). In fact, the results for mean SD (0.44mm for both nuclei) are below the actual
image resolution of the datasets (0.7mm), consistent with a high level of accuracy.
Extension of methods to other structures
Here we have focused on the two most common DBS targets, STN and GPi, though
this method may also be applicable to other small subcortical structures such as thalamic
nuclei or the nucleus accumbens. The borders of these structures lack distinct MRI
contrasts which may reduce the ability to accurately align them to template space. Still, our
results show that the STN can still be segmented well even when only using T1-weighted
MRI as an input, where STN contrast is very poor. This is accomplished by registering
surrounding structures with sufficient image contrast as accurately as possible. Given the
phylogenetic age of subcortical structures, displacement across subjects is likely to be less
than it is for cortical folds. For the thalamus specifically, the methods proposed here could
potentially adjust for alterations in the overall size and shape of the thalamus, as well as
potentially align intrathalamic structures like the internal medullary lamina which are
discernible on MRI. Still, absent histology, we lack for a gold standard to segment the
thalamus into its subnuclei, which limits the ability to explicitly assess the performance of
automated segmentation algorithms for these structures.
Volumes of segmented STN and GPi
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Running title: Evaluation of normalization methods for subcortical segmentation
We found a marginal but significant difference in volumes of the segmented STNs
across all YC subjects with a slightly higher volume for the left STN (mean volume left STN
= 122mm3, right STN = 118mm3). This left-right asymmetry has previously been reported
in larger cohorts (e.g., 120 subjects in Shen and Gao, 2009 and 168 STNs in Nowinski et
al., 2005). For the PC we could not replicate this finding, perhaps due to a lower number of
segmented subjects and resulting reduced statistical power for such small absolute
volume differences. Our STN volumes are in line with other histology studies with volumes
ranging from 119 to 139mm3 for the STN (Zwirner et al., 2016; Mai et al., 2015; Hardman
et al., 2002). In addition to the high inter-rater overlap, these findings give us additional
confidence in the quality of our manual segmentations.
Limitations
The study has several limitations. There is no definitive test to assess whether an
algorithm is performing optimally. As such, we cannot rule out that further optimizations of
ANTs, SPM or other algorithms (e.g., FNIRT) could outperform the results reported here.
We therefore are careful not to claim that the performance ranking reported here could not
be altered by, for example, further adapting the preset parameters of the FSL method for
better subcortical alignment. Second, we used datasets of healthy subjects for this study,
although we included an age- and quality-matched cohort to resemble a typical
Parkinson’s disease. Nevertheless, we have not directly assessed the performance of
these algorithms in a clinical cohort. Furthermore, here, we focused on routinely available
acquisitions (T1-, T2-, PD-) instead of specialized basal ganglia sequences such as QSM
or FGATIR that are increasingly utilized in DBS surgical planning. Of note, however, our
final results still performed competitively with respect to results of a recent study that used
these sequences for automated segmentation (Garzón et al., 2017).
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Running title: Evaluation of normalization methods for subcortical segmentation
Lastly, the present results show how well automatic segmentation reproduces
manual segmentations of basal ganglia structures as visible on MRI. Although these
results suggest that modern automatic procedures are (nearly) able to reproduce the work
of expert humans, there remains a gap between the MRI-defined structure and the true
boundary of the structures as demonstrated on histology. The size of the subthalamic
nucleus and pallidum are both larger on histology than on MRI (Dormont et al. 2004;
Richter et al. 2004; Schäfer et al. 2011; de Hollander et al. 2014; Massey et. al 2012). For
the STN, much of the MRI imaging contrast derives from iron deposition which is not
uniform within the nucleus. Rather, it exhibits a gradient that decays from anterior to
posterior similar to the gradient in cellular density (de Hollander et al. 2014; Marani et al.
2008). As we did not have histologic data for the subjects studied here, we can not
address these discrepancies directly. It is possible that ongoing technical refinements in
MRI including quantitative susceptibility mapping (Alkemade et al. 2017) and high-field
MRI imaging (Forstmann et al. 2017) may narrow this gap in the future.
Conclusions
In conclusion, we have presented a detailed, validated approach to i) select
nonlinear warping algorithms including their parameters and presets and ii) justify the use
of atlas-based segmentations for automated definition of DBS targets. We see that several
future innovations could further improve on these results. For one, incorporation of the
aforementioned specialized basal ganglia sequences (QSM and FGATIR) may further
improve accuracy and robustness.
We have released our 103-brain manually segmented dataset as an evaluation tool
that can be used to assess the performance of future iterations of image registration
algorithms. We plan to integrate this dataset into the open source toolbox Lead-DBS, of
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Running title: Evaluation of normalization methods for subcortical segmentation
which the code is accessible through Github (https://github.com/leaddbs/leaddbs/). The
optimal pipeline evaluated in the present study is included as the default preset in Lead-
DBS. Code to perform evaluations of new methods similar to the present study will be
included as an addition to the toolbox. We hope that other groups will build on our results
to further optimize approaches to atlas-based segmentation.
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Running title: Evaluation of normalization methods for subcortical segmentation
Acknowledgements
The authors would especially like to thank Dr. Brian Edlow and Dr. Bruce Fischl for
providing us with high-resolution post-mortem human MRI scans that showed the
target structures in detail and guided our manual segmentation.
Funding
This research was supported in part by NINDS grant K23NS099380 and an
American Academy of Neurology / American Brain Foundation Clinical Research
Training Fellowship to TMH. The project was further supported by the German
Research Council, DFG grant KFO247.
Conflict of Interest
All authors report no conflicts of interest.
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Running title: Evaluation of normalization methods for subcortical segmentation
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Methods
Table 1: Non-linear image registration methods evaluated.
Software
ID
Full name
Citation
URL
SPM12 (7219)
New Segment
Unified
segmentation.
Ashburner and
Friston, 2005
http://
www.fil.ion.ucl.ac.uk
/spm/software/
spm12/
DARTEL
A fast diffeomorphic
image registration
algorithm.
Ashburner, 2007
SHOOT
Diffeomorphic
registration using
geodesic shooting
and Gauss–Newton
optimisation
Ashburner and
Friston, 2011
FSL 5.0.10
FNIRT
FSL Non-linear
registration
Andersson et al.,
2010
https://
fsl.fmrib.ox.ac.uk/fsl/
fslwiki/FSL
ANTs 2.2.0
SyN
Symmetric
diffeomorphic image
registration
Avants et al., 2010
http://
stnava.github.io/
ANTs/
BSplineSyN
Explicit B-spline
regularization in
diffeomorphic image
registration
Tustison, 2013
Lead-DBS 2.1.0
Linear Threestep
Linear Threestep
Registration with
Focus on Basal
Ganglia and
Brainstem
Schonecker et al.,
2009
http://www.lead-
dbs.org/
Results
Table 2a) Dice coefficients for the Young Cohort. Values are shown from lowest to
highest. For each method only the best performing preset and dataset tested are shown.
Table 2b) Dice coefficients for the Pseudo-Clinical Cohort, as per Table 2a.
Young Cohort
(YC)
Both Nuclei
STN
GPi
Method
Median
Std.
Range
Median
Std.
Range
Median
Std.
Range
Linear
0.56
0.21
0 - 0.86
0.48
0.21
0 - 0.81
0.64
0.18
0.01 - 0.86
SPM SHOOT
0.67
0.10
0.26 - 0.83
0.65
0.11
0.26 - 0.82
0.67
0.09
0.34 - 0.83
SPM DARTEL
0.68
0.08
0.39 - 0.83
0.68
0.07
0.39 - 0.83
0.68
0.06
0.50 - 0.82
FNIRT
0.70
0.10
0.21 - 0.87
0.67
0.09
0.21 - 0.80
0.76
0.09
0.30 - 0.87
SPM Segment
0.73
0.10
0.35 - 0.88
0.70
0.10
0.35 - 0.87
0.78
0.08
0.46 - 0.88
ANTs
0.74
0.07
0.47 - 0.88
0.72
0.06
0.52 - 0.83
0.75
0.07
0.47 - 0.88
Inter-Rater
0.78
0.08
0.54 - 0.88
0.76
0.09
0.54 - 0.88
0.80
0.05
0.70 - 0.88
Pseudo-Clinical
Cohort (PC)
Both Nuclei
STN
GPi
Method
Median
Std.
Range
Median
Std.
Range
Median
Std.
Range
Linear
0.57
0.19
0.06 - 0.82
0.48
0.20
0.06 - 0.75
0.62
0.15
0.26 - 0.82
SPM DARTEL
0.57
0.14
0.13 - 0.79
0.55
0.14
0.13 - 0.79
0.61
0.14
0.21 - 0.78
FNIRT
0.58
0.18
0.06 - 0.82
0.58
0.17
0.12 - 0.76
0.58
0.19
0.06 - 0.82
SPM SHOOT
0.59
0.16
0.02 - 0.81
0.58
0.18
0.02 - 0.78
0.62
0.13
0.27 - 0.81
SPM Segment
0.64
0.13
0.17 - 0.85
0.62
0.12
0.16 - 0.79
0.68
0.14
0.23 - 0.85
Inter-Rater
0.66
0.08
0.41- 0.81
0.66
0.10
0.41 - 0.81
0.65
0.06
0.51 - 0.79
ANTs
0.68
0.10
0.41 - 0.86
0.67
0.09
0.41 - 0.82
0.71
0.09
0.44 - 0.86
Table 3a) Dice coefficient, median and mean surface distance (SD) and volumes for
the YC. For SD of STN segmentations, ANTs SyN shows a lower median value than the
inter-rater agreement. For the GPi there was no significant difference between either
method and inter-rater values. For the Dice values, except for SPM Segment in the GPi,
inter-rater results were slightly but significantly higher than both evaluated methods. Inter-
rater volumes as well as volumes from automated segmentation are comparable in size
with ANTs tending to result in slightly bigger volumes.
YOUNG
COHORT (YC)
STN
GPi
Median
Mean
Std.
Range
Median
Mean
Std.
Range
Dice
Coeff.
Segment
0.70
0.67
0.10
0.35 - 0.87
0.78
0.76
0.08
0.46 - 0.88
ANTs
0.72
0.72
0.06
0.52 - 0.83
0.75
0.75
0.07
0.47 - 0.88
Inter-Rater
0.76
0.75
0.09
0.54 - 0.88
0.80
0.79
0.05
0.70 - 0.88
SD mm
Segment
0.45
0.48
0.14
0.21 - 1.19
0.45
0.48
0.16
0.25 - 1.05
ANTs
0.38
0.38
0.07
0.24 - 0.72
0.49
0.49
0.12
0.22 - 0.87
Inter-Rater
0.41
0.45
0.20
0.21 - 1.00
0.45
0.49
0.14
0.31 - 0.83
Volume
mm3
Segment
117
119
12
96 - 152
372
377
34
311 - 474
ANTs
147
148
15
118 - 193
397
406
40
340 - 546
Inter-Rater
119
120
20
68 - 168
363
359
50
231 - 473
Table 3b) Dice coefficient, median and mean surface distance (SD) and volumes for
the PC. This dataset was more difficult to segment for the manual raters due to lower
SNR and resolution. Inter-rater reliability measured by Dice value or SD was lower
compared to YC. Automated atlas-based segmentation by ANTs SyN and SPM Segment
performed similarly to inter-rater results. Again, volumes from automated segmentation
result in similar sizes as inter-rater volumes.
PSEUDO-CLINICAL
COHORT (PC)
STN
GPi
Median
Mean
Std.
Range
Median
Mean
Std.
Range
Dice
Coeff.
Segment
0.62
0.60
0.12
0.16 - 0.79
0.68
0.64
0.14
0.23 - 0.85
ANTs
0.67
0.65
0.09
0.41 - 0.82
0.71
0.70
0.09
0.44 - 0.86
Inter-Rater
0.66
0.66
0.10
0.41 - 0.81
0.65
0.65
0.06
0.51 - 0.79
SD mm
Segment
0.52
0.55
0.20
0.21 - 1.27
0.73
0.79
0.38
0.30 - 1.80
ANTs
0.61
0.64
0.19
0.31 - 1.16
0.75
0.82
0.30
0.41 - 1.75
Inter-Rater
0.64
0.72
0.25
0.40 - 1.30
0.82
0.86
0.16
0.53 - 1.18
Volume
mm3
Segment
110
112
12
83 - 142
356
357
32
279 - 428
ANTs
117
118
10
93 - 135
372
380
36
305 - 460
Inter-Rater
113
112
19
74 - 154
324
324
62
157 - 434
Table 4: Computational demands of different algorithms. Time needed (rounded, in
minutes) to perform a nonlinear image registration with the methods and presets
presented in this paper. Results are organized from fastest to slowest. The two methods
that performed best in our analyses (SPM Segment and ANTs SyN with the best preset)
are highlighted.
Method
MacBook Pro
Desktop PC
1
SPM New Segment
10
5
2
SHOOT
15
8
3
DARTEL
24
13
4
ANTs SyN mid Variance
31
8
5
ANTs SyN low Variance
33
9
6
ANTs SyN high Variance
36
8
7
ANTs SyN low Variance with subcortical
refine
42
13
8
ANTs BSplineSyN high Variance
43
12
9
ANTs BSplineSyN mid Variance
45
12
10
FNIRT
126
35
11
ANTs BSplineSyN low Variance
1090
197
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The subthalamic nucleus (STN) is a primary target for deep brain stimulation in Parkinson's disease (PD). Although small in size, the STN is commonly partitioned into sensorimotor, cognitive/associative, and limbic subregions based on its structural connectivity profile to cortical areas. We investigated whether such a regional specialization is also supported by functional connectivity between local field potential recordings and simultaneous magnetoencephalography. Using a novel data set of 21 PD patients, we replicated previously reported cortico-STN coherence networks in the theta/alpha and beta frequency ranges, and looked for the spatial distribution of these networks within the STN region. Although theta/alpha and beta coherence peaks were both observed in on-medication recordings from electrode contacts at several locations within and around the STN, sites with theta/alpha coherence peaks were situated at significantly more inferior MNI coordinates than beta coherence peaks. Sites with only theta/alpha coherence peaks, i.e. without distinct beta coherence, were mostly located near the border of sensorimotor and cognitive/associative subregions as defined by a tractography-based atlas of the STN. Peak coherence values were largely unaltered by the medication state of the subject, however, theta/alpha peaks were more often identified in recordings obtained after administration of dopaminergic medication. Our findings suggest the existence of a frequency-specific topography of cortico-STN coherence within the STN, albeit with considerable spatial overlap between functional networks. Consequently, optimization of deep brain stimulation targeting might remain a trade-off between alleviating motor symptoms and avoiding adverse neuropsychiatric side effects.
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Epidemiological studies suggest that a single moderate-to-severe traumatic brain injury (TBI) is associated with an increased risk of neurodegenerative disease, including Alzheimer's and Parkinson's disease (AD and PD). Histopathological studies describe complex neurodegenerative pathologies in individuals exposed to single moderate-to-severe TBI or repetitive mild TBI, including chronic traumatic encephalopathy (CTE). However, the clinicopathological links between TBI and post-traumatic neurodegenerative diseases such as AD, PD, and CTE remain poorly understood. Here we describe the methodology of the Late Effects of TBI (LETBI) study, whose goals are to characterize chronic post-traumatic neuropathology and to identify in vivo biomarkers of post-traumatic neurodegeneration. LETBI participants undergo extensive clinical evaluation using National Institutes of Health TBI Common Data Elements, proteomic and genomic analysis, structural and functional MRI, and prospective consent for brain donation. Selected brain specimens undergo ultra-high resolution ex vivo MRI and histopathological evaluation including whole mount analysis. Co-registration of ex vivo and in vivo MRI data enables identification of ex vivo lesions that were present during life. In vivo signatures of postmortem pathology are then correlated with cognitive and behavioral data to characterize the clinical phenotype(s) associated with pathological brain lesions. We illustrate the study methods and demonstrate proof of concept for this approach by reporting results from the first LETBI participant, who despite the presence of multiple in vivo and ex vivo pathoanatomic lesions had normal cognition and was functionally independent until her mid-80s. The LETBI project represents a multidisciplinary effort to characterize post-traumatic neuropathology and identify in vivo signatures of postmortem pathology in a prospective study.
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Background: The gold standard for post-operative deep brain stimulation (DBS) parameter tuning is a monopolar review of all stimulation contacts, a strategy being challenged by recent developments of more complex electrode leads. Objective: Providing a method to guide clinicians on DBS assessment and parameter tuning by automatically integrating patient individual data. Methods: We present a fully automatic method for visualization of individual deep brain structures in relation to a DBS lead by combining precise electrode recovery from post-operative imaging with individual estimates of deep brain morphology utilizing a 7T-MRI deep brain atlas. Results: The method was evaluated on 20 STN DBS cases. It demonstrated robust automatic creation of 3D-enabled PDF reports visualizing electrode to brain structure relations and proved valuable in detecting miss placed electrodes. Discussion: Automatic DBS assessment is feasible and can conveniently provide clinicians with relevant information on DBS contact positions in relation to important anatomical structures.
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Deep brain stimulation (DBS) is a neurosurgical intervention where electrodes are permanently implanted into the brain in order to modulate pathologic neural activity. The post-operative reconstruction of the DBS electrodes is important for an efficient stimulation parameter tuning. A major limitation of existing approaches for electrode reconstruction from post-operative imaging that prevents the clinical routine use is that they are manual or semi-automatic, and thus both time-consuming and subjective. Moreover, the existing methods rely on a simplified model of a straight line electrode trajectory, rather than the more realistic curved trajectory. The main contribution of this paper is that for the first time we present a highly accurate and fully automated method for electrode reconstruction that considers curved trajectories. The robustness of our proposed method is demonstrated using a multi-center clinical dataset consisting of N = 44 electrodes. In all cases the electrode trajectories were successfully identified and reconstructed. In addition, the accuracy is demonstrated quantitatively using a high-accuracy phantom with known ground truth. In the phantom experiment, the method could detect individual electrode contacts with high accuracy and the trajectory reconstruction reached an error level below 100 micron (0.046 ± 0.025 mm). An implementation of the method is made publicly available such that it can directly be used by researchers or clinicians. This constitutes an important step towards future integration of lead reconstruction into standard clinical care.
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The subthalamic nucleus (STN) plays a crucial role in the surgical treatment of Parkinson’s disease (PD). Studies investigating optimal protocols for STN visualization using state of the art magnetic resonance imaging (MRI) techniques have shown that susceptibility weighted images, which display the magnetic susceptibility distribution, yield better results than T1-weighted, T2-weighted, and T2*-weighted contrasts. However, these findings are based on young healthy individuals, and require validation in elderly individuals and persons suffering from PD. Using 7T MRI, the present study set out to investigate which MRI contrasts yielded the best results for STN visualization in 12 PD patients and age-matched healthy controls (HC). We found that STNs were more difficult to delineate in PD as reflected by a lower inter-rater agreement when compared to HCs. No STN size differences were observed between the groups. Analyses of quantitative susceptibility mapping (QSM) images showed a higher inter-rater agreement reflected by increased Dice-coefficients. The location of the center of mass of the STN was not affected by contrast. Overall, contrast-to-noise ratios (CNR) were higher in QSM than in T2*-weighted images. This can at least partially, explain the higher inter-rater agreement in QSM. The current results indicate that the calculation of QSM contrasts contributes to an improved visualization of the entire STN. We conclude that QSM contrast is the preferred choice for the visualization of the STN in persons with PD as well as in aging HC.
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This monograph gives an overview of the STN. It treats the position of the STN in hemiballism, based on older and recent data. The cytology encompasses the neuronal types present in the STN in nearly all studied species and focuses on interneurons and the extent of their dendrites. Ultrastructural features are described for cat and baboon (F1, F2, Sr, LR1, LR2 boutons and d.c.v. terminals, together with vesicle containing dendrites), the cytochemistry is focused on receptors (dopamine, cannabinoid, opioid, glutamate, GABA, serotonin, and cholinergic-, purinergic ones) and calcium binding proteins and calcium channels. The development of the subthalamic nucleus from the subthalamic cell cord is given together with its developing connections. The topography of rat, cat, baboon and man is worked out as to cytology, sagittal borders, surrounding nuclei and tracts, and aging of the human STN. The connections of the STN are extensively elaborated on: cortical-, subthalamo-cortical-, pallidosubthalamic-, pedunculopontine-, raphe-, thalamic-, central grey-, and nigral connections. Emphasis is put on human connections. Recent nigro-subthalamic studies showed a contralateral projection. The role of the STN in the basal ganglia circuitry is described as to the direct, indirect and hyperdirect pathway. The change the STN undergoes in Parkinson’s disease in neuronal firing rate and firing pattern is demonstrated together with the possible mechanisms of deep brain stimulation. The results of in vitro measurements on dissociated cultured subthalamic neurons are presented. The preliminary effects of application of acetylcholine and high frequency stimulation are described. This part is preceded with studies concerning spontaneous activity, depolarizing and hyperpolarizing inputs, synaptic inputs, high frequency stimulation, and burst activity of STN cells. The last extensive part concerns STN cell models and simulation of neuronal networks. Single cell models (model of Otsuka and Terman/Rubin) are compared and the multi-compartment model of Gillies and Willshaw is explored. The globus pallidus externus-STN network as proposed by Terman is briefly described. The monograph finishes with a series of interpretations of the results.
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The substantia nigra (SN), the subthalamic nucleus (STN), and the red nucleus (RN) are midbrain structures of ample interest in many neuroimaging studies, which may benefit from the availability of automated segmentation methods. The high iron content of these structures awards them high contrast in quantitative susceptibility mapping (QSM) images. We present a novel segmentation method that leverages the information of these images to produce automated segmentations of the SN, STN, and RN. The algorithm builds a map of spatial priors for the structures by non-linearly registering a set of manually-traced training labels to the midbrain. The priors are used to inform a Gaussian mixture model of the image intensities, with smoothness constraints imposed to ensure anatomical plausibility. The method was validated on manual segmentations from a sample of 40 healthy younger and older subjects. Average Dice scores were 0.81 (0.05) for the SN, 0.66 (0.14) for the STN and 0.88 (0.04) for the RN in the left hemisphere, and similar values were obtained for the right hemisphere. In all structures, volumes of manual and automatically obtained segmentations were significantly correlated. The algorithm showed lower accuracy on and T2-weighted Fluid Attenuated Inversion Recovery (FLAIR) images, which are also sensitive to iron content. To illustrate an application of the method, we show that the automated segmentations were comparable to the manual ones regarding detection of age-related differences to putative iron content.
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Objective: The benefit of deep brain stimulation (DBS) for Parkinson's disease (PD) may depend on connectivity between the stimulation site and other brain regions, but which regions and whether connectivity can predict outcome in patients remains unknown. Here, we identify the structural and functional connectivity profile of effective DBS to the subthalamic nucleus (STN) and test its ability to predict outcome in an independent cohort. Methods: A training dataset of 51 PD patients with STN DBS was combined with publicly available human connectome data (diffusion tractography and resting state functional connectivity) to identify connections reliably associated with clinical improvement (motor score of Unified Parkinson's Disease Rating Scale). This connectivity profile was then used to predict outcome in an independent cohort of 44 patients from a different center. Results: In the training dataset, connectivity between the DBS electrode and a distributed network of brain regions correlated with clinical response including structural connectivity to supplementary motor area and functional anticorrelation to primary motor cortex (p < 0.001). This same connectivity profile predicted response in an independent patient cohort (p < 0.01). Structural and functional connectivity were independent predictors of clinical improvement (p < 0.001) and estimated response in individual patients with an average error of 15% UPDRS improvement. Results were similar using connectome data from normal subjects or a connectome age, sex, and disease-matched to our DBS patients. Interpretation: Effective STN-DBS for PD is associated with a specific connectivity profile that can predict clinical outcome across independent cohorts. This prediction does not require specialized imaging in PD patients themselves. This article is protected by copyright. All rights reserved.
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Three-dimensional atlases of subcortical brain structures are valuable tools to reference anatomy in neuroscience and neurology. For instance, they can be used to study the position and shape of the three most common deep brain stimulation (DBS) targets, the sub-thalamic nucleus (STN), internal part of the pallidum (GPi) and ventral intermediate nucleus of the thalamus (VIM) in stereotactic space and in spatial relationship to DBS electrodes. Here, we present a composite atlas that is based on manual segmentations of a multimodal high resolution brain template, histology and structural connectivity. In a first step, four key structures were defined on the template itself using a combination of multi-spectral image analysis and manual segmentation. Second, these structures were used as anchor points to coregister a detailed histological atlas into standard space. Results show that this approach significantly improved coregistration accuracy over previously published methods. Finally, a sub-segmentation of STN and GPi into functional zones was achieved based on structural connectivity. The result is a composite atlas that defines key nuclei on the template itself, fills the gaps between them using histology and further subdivides them using structural connectivity. We show that the atlas can be used to segment DBS targets in single subjects, yielding more accurate results compared to priorly published atlases. The atlas will be made publicly available and constitutes a resource to study DBS electrode localizations in combination with modern neuroimaging methods.