Accuracy, precision, and safety of stereotactic, frame-based, intraoperative MRI-guided and MRI-verified deep brain stimulation in 650 consecutive procedures

Abstract

OBJECTIVE Suboptimal lead placement is one of the most common indications for deep brain stimulation (DBS) revision procedures. Confirming lead placement in relation to the visible anatomical target with dedicated stereotactic imaging before terminating the procedure can mitigate this risk. In this study, the authors examined the accuracy, precision, and safety of intraoperative MRI (iMRI) to both guide and verify lead placement during frame-based stereotactic surgery. METHODS A retrospective analysis of 650 consecutive DBS procedures for targeting accuracy, precision, and perioperative complications was performed. Frame-based lead placement took place in an operating room equipped with an MRI machine using stereotactic images to verify lead placement before removing the stereotactic frame. Immediate lead relocation was performed when necessary. Systematic analysis of the targeting error was calculated. RESULTS Verification of 1201 DBS leads with stereotactic MRI was performed in 643 procedures and with stereotactic CT in 7. The mean ± SD of the final targeting error was 0.9 ± 0.3 mm (range 0.1–2.3 mm). Anatomically acceptable lead placement was achieved with a single brain pass for 97% (n = 1164) of leads; immediate intraoperative relocation was performed in 37 leads (3%) to obtain satisfactory anatomical placement. General anesthesia was used in 91% (n = 593) of the procedures. Hemorrhage was noted after 4 procedures (0.6%); 3 patients (0.4% of procedures) presented with transient neurological symptoms, and 1 experienced delayed cognitive decline. Two bleeds coincided with immediate relocation (2 of 37 leads, 5.4%), which contrasts with hemorrhage in 2 (0.2%) of 1164 leads implanted on the first pass (p = 0.0058). Three patients had transient seizures in the postoperative period. The seizures coincided with hemorrhage in 2 of these patients and with immediate lead relocation in the other. There were 21 infections (3.2% of procedures, 1.5% in 3 months) leading to hardware removal. Delayed (> 3 months) retargeting of 6 leads (0.5%) in 4 patients (0.6% of procedures) was performed because of suboptimal stimulation benefit. There were no MRI-related complications, no permanent motor deficits, and no deaths. CONCLUSIONS To the authors’ knowledge, this is the largest series reporting the use of iMRI to guide and verify lead location during DBS surgery. It demonstrates a high level of accuracy, precision, and safety. Significantly higher hemorrhage was encountered when multiple brain passes were required for lead implantation, although none led to permanent deficit. Meticulous audit and calibration can improve precision and maximize safety.

Measuring the orientation of segmented Deep Brain Stimulation leads using electroencephalography

“…Importantly, knowledge of the precise lead position is required. This applies to most DBS surgeries verified with postoperative CT/MRI coregistered to preoperative structural image [13,21]. In fact, the lead location in a patient is likely measured more precisely than in our phantom.…”

“…Here, in a phantom experiment, we show that electroencephalography (EEG), informed by post-operative imaging [13] can precisely determine lead orientation.…”

Preclinical assessment of a noncooled MR thermometry–based neurosurgical laser therapy system

“…Both errors were consistently less than 1 mm, which is in line with current accuracy and precision reported in other intraoperative MRI-guided stereotactic procedures like deep brain stimulation lead placement. 28 High accuracy was especially important while targeting small structures in preclinical animal models.…”

Comparison of Navigated and Frame-Based Stereotactic Biopsy—A Single-Center Cohort Study

“…This result may be caused by higher target error. The mean target error for the frame-based procedure is 0.9 ± 0.3 mm [ 21 ]. The mean target error for frameless procedures is 2.7 ± 0.56 mm [ 22 ].…”