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Improving Targeting in Image-Guided Frame-Based Deep Brain Stimulation

Holl, Etienne M MD1; Petersen, Erika A MD2; Foltynie, Thomas MRCP, PhD3; Martinez-Torres, Irene MD4; Limousin, Patricia MD, PhD3; Hariz, Marwan I MD, PhD5; Zrinzo, Ludvic MD, MSc, FRCS (NeuroSurg)6

doi: 10.1227/NEU.0b013e3181f7422a
Operative Technique

BACKGROUND: Deep brain stimulation (DBS) is commonly used in the treatment of movement disorders such as Parkinson disease (PD), dystonia, and other tremors.

OBJECTIVE: To examine systematic errors in image-guided DBS electrode placement and to explore a calibration strategy for stereotactic targeting.

METHODS: Pre- and postoperative stereotactic MR images were analyzed in 165 patients. The perpendicular error between planned target coordinates and electrode trajectory was calculated geometrically for all 312 DBS electrodes implanted. Improvement in motor unified PD rating scale III subscore was calculated for those patients with PD with at least 6 months of follow-up after bilateral subthalamic DBS.

RESULTS: Mean (standard deviation) scalar error of all electrodes was 1.4(0.9) mm with a significant difference between left and right hemispheres. Targeting error was significantly higher for electrodes with coronal approach angle (ARC) ≥10° (P < .001). Mean vector error was X: −0.6, Y: −0.7, and Z: −0.4 mm (medial, posterior, and superior directions, respectively). Targeting error was significantly improved by using a systematic calibration strategy based on ARC and target hemisphere (mean: 0.6 mm, P < .001) for 47 electrodes implanted in 24 patients. Retrospective theoretical calibration for all 312 electrodes would have reduced the mean (standard deviation) scalar error from 1.4(0.9) mm to 0.9(0.5) mm (36% improvement). With calibration, 97% of all electrodes would be within 2 mm of the intended target as opposed to 81% before calibration. There was no significant correlation between the degree of error and clinical outcome from bilateral subthalamic nucleus DBS (R2 = 0.07).

CONCLUSION: After calibration of a systematic targeting error an MR image-guided stereotactic approach would be expected to deliver 97% of all electrodes to within 2 mm of the intended target point with a single brain pass.

1Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom; and Department of Neurosurgery, Medical University, Graz, Austria

2Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom; and Department of Neurosurgery, University of Texas, Southwestern, Dallas, Texas

3Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom

4Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom; and Department of Neurology, Hospital La Fe, Valencia, Spain

5Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom; and Department of Neurosurgery, University Hospital, Umeå, Sweden

6Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom

Received, December 29, 2009.

Accepted, June 7, 2010.

Reprint requests: Ludvic Zrinzo, MD, MSc, FRCS (NeuroSurg), Unit of Functional Neurosurgery, Box 146, Institute of Neurology and National Hospital for Neurology and Neurosurgery, 33 Queen Square, London, WC1N 3BG, United Kingdom. E-mail: l.zrinzo@ion.ucl.ac.uk

Copyright © by the Congress of Neurological Surgeons