J Korean Med Sci.  2011 Oct;26(10):1344-1355. 10.3346/jkms.2011.26.10.1344.

Electrode Position and the Clinical Outcome after Bilateral Subthalamic Nucleus Stimulation

• Paek SH
• Lee JY
• Kim HJ
• Kang D
• Lim YH
• Kim MR
• Kim C
• Jeon BS
• Kim DG

• KMID: 1785994
• DOI: http://doi.org/10.3346/jkms.2011.26.10.1344

Abstract

We compared the surgical outcome with electrode positions after bilateral subthalamic nucleus (STN) stimulation surgery for Parkinson's disease. Fifty-seven patients treated with bilateral STN stimulations were included in this study. Electrode positions were determined in the fused images of preoperative MRI and postoperative CT taken at six months after surgery. The patients were divided into three groups: group I, both electrodes in the STN; group II, only one electrode in the STN; group III, neither electrode in the STN. Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr stage, and activities of daily living scores significantly improved at 6 and 12 months after STN stimulation in both group I and II. The off-time UPDRS III speech subscore significantly improved (1.6 +/- 0.7 at baseline vs 1.3 +/- 0.8 at 6 and 12 months, P < 0.01) with least L-dopa equivalent daily dose (LEDD) (844.6 +/- 364.1 mg/day at baseline; 279.4 +/- 274.6 mg/day at 6 months; and 276.0 +/- 301.6 mg/day at 12 months, P < 0.001) at 6 and 12 months after STN deep brain stimulation (DBS) in the group I. Our findings suggest that the better symptom relief including speech with a reduced LEDD is expected in the patients whose electrodes are accurately positioned in both STN.

Keyword

Parkinson Disease; Bilateral STN Stimulation; Clinical Outcome; Electrode Position; Fused Images

MeSH Terms

Adult
Aged
Antiparkinson Agents/adverse effects/*therapeutic use
Combined Modality Therapy
*Deep Brain Stimulation/adverse effects/instrumentation/methods
*Electrodes, Implanted
Female
Humans
Levodopa/adverse effects/therapeutic use
Magnetic Resonance Imaging
Male
Middle Aged
Parkinson Disease/drug therapy/*therapy
Severity of Illness Index
Subthalamic Nucleus/*physiology
Treatment Outcome

Figure

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  Fig. 1 Fused images of the preoperative MRI and postoperative CT. The T2-weighted axial images of brain MRI taken before surgery are fused with 3-D spiral CT scan images at the data set of 1-mm thickness reformatted images, aligned to anterior commissure - posterior commissure (AC-PC) line. The midline of reformatted coronal images also intersect the midsagittal plane for the correction of head-rotation error. The length of AC-PC line and width of the third ventricle are taken into consideration for the proportional localization of the electrodes position in the human brain atlas of Schaltenbrad and Wahren. In the reformatted axial images the lateral distance from the midline and the anteroposterior distance from the mid-commissural line to each electrode are measured (A). In the reformatted coronal images in which the electrode trajectory is best visualized, the lateral angles of the electrode trajectory from the midline are measured for each electrode in every patient (B). In the reformatted sagittal images in which the electrode trajectory is best shown, the antero-posterior angle of the electrode trajectory from the line perpendicular to the AC-PC line and the depth of the electrodes are also measured for each electrode in every patient (C).

• 

  Fig. 2 Plotting of electrode positions in the human brain atlas. With the information from the fused images of preoperative MRI and postoperative CT taken at 6 months after surgery as shown in Fig. 1, the electrode positions are plotted on the human brain atlas of Schaltenbrand and Wahren in each patient. Representative illustration of the electrode positions (A-C) are plotted in the axial, sagittal, and coronal planes. Based on the axial view at the level of 3.5 mm below the AC-PC line in the atlas, electrode positions (in blue and red colors) are categorized into three groups: 1) group I, both electrodes in the STN (n = 36) (A); 2) group II, only one electrode in the STN (n = 16) (B); 3) group III, neither electrode in the STN (n = 5) (C).

• 

  Fig. 3 Electrode positions of 13 patients without medication after surgery. (A) The location of the electrodes are plotted based on the fused images of the 13 patients showing significant clinical improvement in UPDRS part III including speech with nil LEDD (in red color) and of the remaining 44 patients (in black color) at the last follow-up period of more than one year after surgery. Most electrodes of these 13 patients are positioned in the middle one third of the subthalamic nucleus in the axial view at the level of 3.5 mm below the AC-PC line (upper left), and also positioned in the subthalamic nucleus in the coronal view at the level of 3.0 mm posterior to midcommissural point (upper right) and in the sagittal view at the level of 12 mm lateral to the midline (lower). (B) The x, y, z coordinates of the active contacts referenced to the AC-PC midpoints in the 13 patients with nil LEDD.

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  Fig. 4 Fused images of two brain CT scans taken after surgery. The fused images obtained from the CT scans taken at the immediate postoperative day and six months after surgery are aligned along the AC-PC line at the level of AC and PC in axial, sagittal, and coronal plane. The red represents the electrode extracted from the images of brain CT taken immediately after surgery and the gray represents the electrode extracted from the images of the brain CT taken at six months after surgery. The red and the gray electrodes do not fit into each other with significant discrepancy of their position in the axial and coronal planes (A). With the adjustment of window level and width of the fused images, only the shadow of both electrodes is extracted in 3-D reconstructive rendering image of right superior oblique view (B), right posterior oblique view (C), and AP and lateral view (D). The yellow represents the electrode extracted from the images of brain CT taken immediately after surgery and the sky-blue represents the electrode extracted from the images of the brain CT taken at six months after surgery. Significant discrepancy of the electrode position between the two CT scans is remarkable.

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  Fig. 5 Fused images of brain CT and MRI taken after surgery. Fused images of the brain CT and the brain MRI both taken at 6 months after bilateral subthalamic stimulation are illustrated. The fused images obtained from the brain MRI and the brain CT taken at 6 months after bilateral subthalamic stimulation are aligned along the AC-PC line at the level of AC and PC in axial, sagittal, and coronal plane. The red represents the electrode extracted from the images of brain CT taken at six months after surgery and the gray represents the electrode extracted from the images of the brain MRI taken at six months after surgery. The center of red and gray one representing the center of electrodes extracted from brain CT and brain MRI do not fit into each other with significant discrepancy of their position in the axial, coronal, and sagittal plane of the fused images (A). With the adjustment of window level and width of the fused images, only the electrodes in red color are superimposed in 3-D reconstructive rendering brain MR images of superior anterior view (B), left anterior superior oblique view (C), and anterior posterior view (D). The discrepancy of the electrode position extracted from brain CT and the center of electrode artifact from brain MRI taken at 6 months after surgery is remarkable in all three axial, sagittal, and coronal planes.

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