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A role of diffusion tensor imaging fiber tracking in deep brain stimulation surgery: DBS of the dentato-rubro-thalamic tract (drt) for the treatment of therapy-refractory tremor

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Abstract

Introduction

Deep brain stimulation (DBS) can alleviate tremor of various origins. A number of regions are targeted. In recent work our group was able to show the involvement of the dentato-rubro-thalamic tract (drt) in tremor control with fiber tracking techniques. Here we report for the first time the successful use of magnetic resonance tractography in combination with traditional landmark-based targeting techniques to perform the implantation of a bilateral DBS system in a patient with dystonic head tremor.

Methods

We report on a 37-year-old female with long-standing pure head tremor from myoclonus dystonia. She was identified as a candidate for thalamic DBS. The use of head fixation in a stereotactic frame would blur target symptoms (head tremor) during surgery and was therefore avoided. Her dentate-rubro-thalamic tracts were visualized with preoperative diffusion tensor imaging (DTI) and tractography, and then directly targeted stereotactically with DBS electrodes.

Results

Three months after implantation, tremor control was excellent (>90%). A close evaluation of the active electrode contact positions revealed clear involvement of the drt.

Conclusion

This is the first time that direct visualization of fiber tracts has been employed for direct targeting and successful movement disorder tremor surgery. In the reported case, additional knowledge about the position of the drt, which previously has been shown to be a structure for modulation to achieve tremor control, led to a successful implantation of a DBS system, although there was a lack of intra-operatively testable tremor symptoms. In concordance with studies in optogenetic neuromodulation, fiber tracts are the emerging target structures for DBS. The routine integration of DTI tractography into surgical planning might be a leading path into the future of DBS surgery and will add to our understanding of the pathophysiology of movement disorders. Larger study populations will have to prove these concepts in future research.

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References

  1. Barkhoudarian G, Klochkov T, Sedrak M, Frew A, Gorgulho A, Behnke E, De Salles A (2010) A role of diffusion tensor imaging in movement disorder surgery. Acta Neurochir (Wien) 2089–2095

  2. Benabid AL, Pollak P, Gao D, Hoffmann D, Limousin P, Gay E, Payen I, Benazzouz A (1996) Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg 84:203–214

    Article  PubMed  CAS  Google Scholar 

  3. Burgel U, Madler B, Honey CR, Thron A, Gilsbach J, Coenen VA (2009) Fiber tracking with distinct software tools results in a clear diversity in anatomical fiber tract portrayal. Cen Eur Neurosurg 70:27–35

    Article  PubMed  CAS  Google Scholar 

  4. Butson CR, Maks CB, McIntyre CC (2006) Sources and effects of electrode impedance during deep brain stimulation. Clin Neurophysiol 117:447–454

    Article  PubMed  Google Scholar 

  5. Carpenter MB (1991) Core Text of Neuroanatomy. Williams and Wilkins, Baltimore

    Google Scholar 

  6. Coenen V, Mädler B, Schiffbauer H, Urbach H, Allert N (2011) Individual fiber anatomy of the subthalamic region revealed with DTI—A concept to identify the DBS target for tremor suppression. Neurosurgery 2011 Jan 19. [Epub ahead of print]

  7. Coenen VA, Fromm C, Kronenburger M, Rohde I, Reinacher PC, Becker R, Marks B, Gilsbach JM, Rohde V (2006) Electrophysiological proof of diffusion-weighted imaging-derived depiction of the deep-seated pyramidal tract in human. Zentralbl Neurochir 67:117–122

    Article  PubMed  CAS  Google Scholar 

  8. Coenen VA, Honey CR, Hurwitz T, Rahman AA, McMaster J, Burgel U, Madler B (2009) Medial forebrain bundle stimulation as a pathophysiological mechanism for hypomania in subthalamic nucleus deep brain stimulation for Parkinson's disease. Neurosurgery 64:1106–1114, discussion 1114–1105

    Article  PubMed  Google Scholar 

  9. Deuschl G, Bain P, Brin M (1998) Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee. Mov Disord 13(Suppl 3):2–23

    PubMed  Google Scholar 

  10. Gradinaru V, Mogri M, Thompson K, Henderson J, Deisseroth K (2009) Optical deconstruction of parkinsonian neural circuitry. Science 324(5925):354–359

    Article  PubMed  CAS  Google Scholar 

  11. Gutman DA, Holtzheimer PE, Behrens TE, Johansen-Berg H, Mayberg HS (2009) A tractography analysis of two deep brain stimulation white matter targets for depression. Biol Psychiatry 65:276–282

    Article  PubMed  Google Scholar 

  12. Hamel W, Herzog J, Kopper F, Pinsker M, Weinert D, Muller D, Krack P, Deuschl G, Mehdorn HM (2007) Deep brain stimulation in the subthalamic area is more effective than nucleus ventralis intermedius stimulation for bilateral intention tremor. Acta Neurochir Wien 149:749–758, discussion 758

    Article  PubMed  CAS  Google Scholar 

  13. Hassler R, Mundinger F, Riechert T (1979) Stereotaxis in Parkinson Syndrome. Springer, Berlin, Heidelberg

    Google Scholar 

  14. Kreher BW, Mader I, Kiselev VG (2008) Gibbs tracking: a novel approach for the reconstruction of neuronal pathways. Magn Reson Med 60:953–963

    Article  PubMed  CAS  Google Scholar 

  15. Lozano AM (2000) Vim thalamic stimulation for tremor. Arch Med Res 31:266–269

    Article  PubMed  CAS  Google Scholar 

  16. Mori S, Kaufmann WE, Davatzikos C, Stieltjes B, Amodei L, Fredericksen K, Pearlson GD, Melhem ER, Solaiyappan M, Raymond GV, Moser HW, van Zijl PC (2002) Imaging cortical association tracts in the human brain using diffusion-tensor-based axonal tracking. Magn Reson Med 47:215–223

    Article  PubMed  Google Scholar 

  17. Pinsker MO, Herzog J, Falk D, Volkmann J, Deuschl G, Mehdorn M (2008) Accuracy and distortion of deep brain stimulation electrodes on postoperative MRI and CT. Zentralbl Neurochir 69:144–147

    Article  PubMed  CAS  Google Scholar 

  18. Plaha P, Khan S, Gill SS (2008) Bilateral stimulation of the caudal zona incerta nucleus for tremor control. J Neurol Neurosurg Psychiatry 79:504–513

    Article  PubMed  CAS  Google Scholar 

  19. Plaha P, Patel NK, Gill SS (2004) Stimulation of the subthalamic region for essential tremor. J Neurosurg 101:48–54

    Article  PubMed  Google Scholar 

  20. Schaltenbrand G, Wahren W (1977) Atlas of Stereotaxy of the Human Brain. Thieme

  21. Schoene-Bake JC, Parpaley Y, Weber B, Panksepp J, Hurwitz TA, Coenen VA (2010) Tractographic analysis of historical lesion surgery for depression. Neuropsychopharmacology 35(13):2553–2563, Epub 2010 Aug 25

    Article  PubMed  Google Scholar 

  22. Wakana S, Jiang H, Nagae-Poetscher LM, van Zijl PC, Mori S (2004) Fiber tract-based atlas of human white matter anatomy. Radiology 230:77–87

    Article  PubMed  Google Scholar 

  23. Yousry TA, Schmid UD, Alkadhi H, Schmidt D, Peraud A, Buettner A, Winkler P (1997) Localization of the motor hand area to a knob on the precentral gyrus. A new landmark. Brain 120(Pt 1):141–157

    Article  PubMed  Google Scholar 

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Conflicts of interest

Dr. Coenen and Dr. Allert have received honoraries for lecturing and consulting services (Medtronic, Europe). Dr. Coenen was a clinical collaborator in the development of StealthViz DTI (Medtronic, Navigation, USA).

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Correspondence to Volker A. Coenen.

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Comment

Targeting in functional neurosurgery traditionally has been based on the Stereotatic Atlas, direct anatomical targeting (image-based, generally MRI), and neurophysiological MER (microelectrode recording). Most centers in the world use a combination of the above-mentioned modalities to insert electrodes (or perform a lesioning procedure) in different anatomical nuclei (STN, VIM, Gpi, etc.). Destruction or high frequency stimulation of these gray matter nuclei seems to reduce the abnormal firing activity and indirectly restore normal (or semi-normal) functioning of different neuronal circuits (STN, cortico-striato-pallido-thalamo-cortical; VIM, cerebello-rubro-thalamic, etc.).

DTI as a targeting modality, alongside the traditional methods, offers a new opportunity in DBS surgery or lesioning (4).

With this modality, it is possible to visualize white matter tracts with better anatomical placement of the electrode (decreased incidence of side effects); moreover, a new target may emerge allowing the possibility of stimulating axons in white matter tracts. This is true in movement disorder surgery, but also in psychosurgery and possibly in epilepsy.

In this very interesting paper, the authors report a case of dystonic head tremor treated with DBS-drt (dentato-rubro-thalamic). The author visualized the drt tract with DTI and directly targeted this area. The postoperative electrode position was confirmed with CT-MRI fusion. Ninety percent head tremor control was achieved at 3 months.

Jibril Osman Farah

Liverpool, UK

The results have not been presented before.

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Coenen, V.A., Allert, N. & Mädler, B. A role of diffusion tensor imaging fiber tracking in deep brain stimulation surgery: DBS of the dentato-rubro-thalamic tract (drt) for the treatment of therapy-refractory tremor. Acta Neurochir 153, 1579–1585 (2011). https://doi.org/10.1007/s00701-011-1036-z

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