Validation of the hotspot for dorsolateral subthalamic nucleus targeting in deep brain stimulation surgery for Parkinson's disease: a post hoc analysis of a randomised controlled trial.

BACKGROUND: Visualisation of the dorsolateral subthalamic nucleus (STN) remains challenging on 1.5 and 3Tesla T2-weighted MRI. Our previously defined hotspot, relative to the well-visualised medial STN border, serves as an MRI landmark for dorsolateral STN identification in deep brain stimulation (DBS). We aimed to validate this hotspot in a separate trial cohort of Parkinson's disease (PD) patients and refine its location. METHODS: In this post hoc analysis of a randomised controlled trial, in which the hotspot was taken into account during target planning, responses to DBS were evaluated using hemibody improvement on the Movement Disorder Society-Unified Parkinson's Disease Rating Scale motor examination and compared with our historical cohort, as well as dopaminergic medication reduction. Then, a refined hotspot was calculated and the Euclidean distance from individual active contacts to the refined hotspot was correlated with motor improvement. RESULTS: The first quartile of the hemibodies (poor responders) showed an average improvement of 13%, which was higher than the -8% in the historical control group (p=0.044). Dopaminergic medication reduction was greater in the current cohort compared with the historical cohort (p=0.020). Overall variability of hemibody motor improvement was reduced in the current cohort compared with the historical control group (p=0.003). Motor improvement correlated to the Euclidean distance from active contact to the refined hotspot (2.8 mm lateral, 1.1 mm anterior and 2.2 mm superior to the medial STN border) (p=0.001). CONCLUSION: We validated the hotspot for dorsolateral STN targeting in DBS for patients with PD and showed an improved motor response in poor responders, a reduced variability in motor improvement and a greater dopaminergic medication reduction. We then refined the hotspot at 2.8 mm lateral, 1.1 mm anterior and 2.2 mm superior relative to the medial STN border, which visualises a readily implementable target within the dorsolateral STN on lower field strength MRI.

Deep Brain Stimulation for Essential Tremor: Aligning Thalamic and Posterior Subthalamic Targets in 1 Surgical Trajectory.

BACKGROUND: Ventral intermediate nucleus (VIM) deep brain stimulation (DBS) and posterior subthalamic area (PSA) DBS suppress tremor in essential tremor (ET) patients, but it is not clear which target is optimal. Aligning both targets in 1 surgical trajectory would facilitate exploring stimulation of either target in a single patient. OBJECTIVE: To evaluate aligning VIM and PSA in 1 surgical trajectory for DBS in ET. METHODS: Technical aspects of trajectories, intraoperative stimulation findings, final electrode placement, target used for chronic stimulation, and adverse and beneficial effects were evaluated. RESULTS: In 17 patients representing 33 trajectories, we successfully aligned VIM and PSA targets in 26 trajectories. Trajectory distance between targets averaged 7.2 (range 6-10) mm. In all but 4 aligned trajectories, optimal intraoperative tremor suppression was obtained in the PSA. During follow-up, active electrode contacts were located in PSA in the majority of cases. Overall, successful tremor control was achieved in 69% of patients. Stimulation-induced dysarthria or gait ataxia occurred in, respectively, 56% and 44% of patients. Neither difference in tremor suppression or side effects was noted between aligned and nonaligned leads nor between the different locations of chronic stimulation. CONCLUSION: Alignment of VIM and PSA for DBS in ET is feasible and enables intraoperative exploration of both targets in 1 trajectory. This facilitates positioning of electrode contacts in both areas, where multiple effective points of stimulation can be found. In the majority of aligned leads, optimal intraoperative and chronic stimulation were located in the PSA.

Deep brain stimulation induces striatal dopamine release in obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder is a chronic psychiatric disorder related to dysfunctional dopaminergic neurotransmission. Deep brain stimulation (DBS) targeted at the nucleus accumbens (NAc) has recently become an effective treatment for therapy-refractory obsessive-compulsive disorder, but its effect on dopaminergic transmission is unknown. METHODS: We measured the effects of NAc DBS in 15 patients on the dopamine D2/3 receptor availability in the striatum with [(123)I]iodobenzamide ([(123)I]IBZM) single photon emission computed tomography. We correlated changes in [(123)I]IBZM binding potential (BP) with plasma levels of homovanillic acid (HVA) and clinical symptoms. RESULTS: Acute (1-hour) and chronic (1-year) DBS decreased striatal [(123)I]IBZM BP compared with the nonstimulated condition in the putamen. BP decreases were observed after 1 hour of stimulation, and chronic stimulation was related to concurrent HVA plasma elevations, implying DBS-induced dopamine release. BP decreases in the area directly surrounding the electrodes were significantly correlated with changes in clinical symptoms (45% symptom decrease). CONCLUSIONS: NAc DBS induced striatal dopamine release, which was associated with increased HVA plasma levels and improved clinical symptoms, suggesting that DBS may compensate for a defective dopaminergic system.

Automatic subthalamic nucleus detection from microelectrode recordings based on noise level and neuronal activity.

Microelectrode recording (MER) along surgical trajectories is commonly applied for refinement of the target location during deep brain stimulation (DBS) surgery. In this study, we utilize automatically detected MER features in order to locate the subthalamic nucleus (STN) employing an unsupervised algorithm. The automated algorithm makes use of background noise level, compound firing rate and power spectral density along the trajectory and applies a threshold-based method to detect the dorsal and the ventral borders of the STN. Depending on the combination of measures used for detection of the borders, the algorithm allocates confidence levels for the annotation made (i.e. high, medium and low). The algorithm has been applied to 258 trajectories obtained from 84 STN DBS implantations. MERs used in this study have not been pre-selected or pre-processed and include all the viable measurements made. Out of 258 trajectories, 239 trajectories were annotated by the surgical team as containing the STN versus 238 trajectories by the automated algorithm. The agreement level between the automatic annotations and the surgical annotations is 88%. Taking the surgical annotations as the golden standard, across all trajectories, the algorithm made true positive annotations in 231 trajectories, true negative annotations in 12 trajectories, false positive annotations in 7 trajectories and false negative annotations in 8 trajectories. We conclude that our algorithm is accurate and reliable in automatically identifying the STN and locating the dorsal and ventral borders of the nucleus, and in a near future could be implemented for on-line intra-operative use.

Stereotactic neurosurgery for tremor.

The role of the motor thalamus as surgical target in stereotactic neurosurgery for different kinds of tremor is discussed. For tremor in Parkinson's disease, the subthalamic nucleus becomes more and more often the surgical target, because this target also gives relief of other and more incapacitating symptoms (hypokinesia, rigidity). Stimulation is as effective in tremor suppression as coagulation but has less adverse events and permits bilateral surgery. In selected cases, thalamotomy can still be indicated.