Implementation of Intraoperative Computed Tomography for Deep Brain Stimulation: Pitfalls and Optimization of Workflow, Accuracy, and Radiation Exposure

Background:The need for imaging-guided optimization of Deep Brain Stimulation (DBS) parameters is increasing with recent developments of sophisticated lead designs offering highly individualized, but time-consuming and complex programming. Objective: The objective of this study was to compare changes in motor symptoms of Parkinson's Disease (PD) and the corresponding volume of the electrostatic field (VEsF) achieved by DBS programming using GUIDE XT™, a commercially available software for visualization of DBS leads within the patient-specific anatomy from fusions of preoperative magnetic resonance imaging (MRI) and postoperative computed tomography (CT) scans, versus standard-of-care clinical programming. Methods: Clinical evaluation was performed to identify the optimal set of parameters based on clinical effects in 29 patients with PD and bilateral directional leads for Subthalamic Nucleus (STN) DBS. A second DBS program was generated in GUIDE XT™ based on a VEsF optimally located within the dorsolateral STN. Reduction of motor symptoms (Movement Disorders Society Unified Parkinson's Disease Rating Scale, MDS-UPDRS) and the overlap of the corresponding VEsF of both programs were compared. Results: Clinical and imaging-guided programming resulted in a significant reduction in the MDS-UPDRS scores compared to off-state. Motor symptom control with GUIDE XT™-derived DBS program was noninferior to standard clinical programming. The overlap of the two VEsF did not correlate with the difference in motor symptom reduction by the programs. Conclusions: Imaging-guided programming of directional DBS leads using GUIDE XT™ is possible without computational background and leads to non-inferior motor symptom control compared with clinical programming. DBS programs based on patient-specific imaging data may thus serve as starting point for clinical testing and may promote more efficient DBS programming.

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“…The preoperative imaging protocol including the GUIDE XT™ workflow as well as the surgical procedure have been reported in Refs. [7,8].…”

Section: Preoperative Imaging and Surgical Proceduresmentioning

confidence: 99%

Imaging-based programming of subthalamic nucleus deep brain stimulation in Parkinson's disease

et al. 2021

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“…However, the operation of these systems can disrupt the normal surgical process, leading to prolonged surgery or anesthesia times. In addition, their expensive price and large floor space requirements can also impact their intraoperative use ( Carl et al, 2018 ; Fuchs-Buder et al, 2018 ). In reagent applications, MRI can only identify the brain and spinal cord, but not peripheral nerve tissue due to the similar signal intensity between the PNS and surrounding tissues ( Maravilla and Bowen, 1998 ).…”

Section: Introductionmentioning

confidence: 99%

Advances in optical molecular imaging for neural visualization

Wei,

Liu,

Liang

et al. 2023

Front. Bioeng. Biotechnol.

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Iatrogenic nerve injury is a significant complication in surgery, which can negatively impact patients’ quality of life. Currently, the main clinical neuroimaging methods, such as computed tomography, magnetic resonance imaging, and high-resolution ultrasonography, do not offer precise real-time positioning images for doctors during surgery. The clinical application of optical molecular imaging technology has led to the emergence of new concepts such as optical molecular imaging surgery, targeted surgery, and molecular-guided surgery. These advancements have made it possible to directly visualize surgical target areas, thereby providing a novel method for real-time identification of nerves during surgery planning. Unlike traditional white light imaging, optical molecular imaging technology enables precise positioning and identifies the cation of intraoperative nerves through the presentation of color images. Although a large number of experiments and data support its development, there are few reports on its actual clinical application. This paper summarizes the research results of optical molecular imaging technology and its ability to realize neural visualization. Additionally, it discusses the challenges neural visualization recognition faces and future development opportunities.

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“…Several strategies have been employed to improve this workflow, including: utilization of bone mounted fiducials placed days prior to surgery, to decouple stereotactic imaging from the day of surgery [1], or the use of real-time magnetic resonance imaging (MRI) with a skull-mounted aiming device [2]. While intraoperative computed tomography (CT) imaging [3, 4] can be done, this requires the presence of a CT technologist in the operating room, and existing portable CT scanners typically cannot be used for intraoperative two-dimensional (2D) fluoroscopy, an important tool for many stereotactic surgeries. A recently available mobile three-dimensional (3D) tomographic imaging system, the Medtronic O-arm O2 (OAO2; Medtronic, Dublin, Ireland), allows for both multiplanar 2D fluoroscopy and 3D tomography (“O-arm spin”) with a wide enough field of view to localize stereotactic frame fiducial markers.…”

Section: Introductionmentioning

confidence: 99%

Intraoperative Stereotactic Frame Registration Using a Three-Dimensional Imaging System with and without Preoperative Computed Tomography for Image Fusion

Spatz

Conner

Young

et al. 2020

Stereotact Funct Neurosurg

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Background: The O-arm O2 imaging system (OAO2) is an intraoperative cone beam 3D tomogram imaging tool with a wide enough field of view to perform intraoperative fiducial registration with standard stereotactic frames. However, the OAO2 3D images (cone beam CT) provide limited tissue contrast, which may reduce the accuracy of fusion to a preoperative targeting MRI for planning awake deep brain stimulation (DBS) surgeries. Therefore, most users obtain a preoperative CT scan to use as the reference exam for computational fusion with the preoperative targeting MRI and the intraoperative OAO2 cone beam CT. Objective: In this study, we retrospectively analyzed the discrepancy between stereotactic coordinates of deep brain targets on MRI derived from intraoperative OAO2 fiducial registration with and without the use of preoperative CT as the reference for image fusion. Methods: Preoperative stereotactic CT/MRI and intraoperative OAO2 cone beam CT were retrospectively evaluated for 27 consecutive DBS patients, using two commercial surgical planning software packages (BrainLab Elements and Medtronic Stealth 8). The anterior commissure, posterior commissure, and left subthalamic nucleus were identified on preoperative MRI. Each patient had intraoperative fiducial registration using the OAO2 with a Leksell head-frame. For each subject, the reference scan for image fusion was set as either the preoperative CT or the preoperative MRI (volumetric T1 with contrast). Computed stereotactic coordinates for each target were then compared. Results: For 8 of 27 subjects, a discrepancy greater than 1.0 mm for at least one designated target was observed utilizing the Medtronic Stealth S8 planning station when a preoperative CT scan was not used. An additional 5 (5/27) had a discrepancy greater than 2 mm. The most common discrepancy was in the z axis. No coordinate discrepancies greater than 1 mm were observed utilizing BrainLab Elements. Conclusions: Caution is advised in fusing intraoperative OAO2 images directly to preoperative MRI without a preoperative CT as the reference exam for image fusion, as the specific fusion algorithm employed may unpredictably affect targeting accuracy.

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Implementation of Intraoperative Computed Tomography for Deep Brain Stimulation: Pitfalls and Optimization of Workflow, Accuracy, and Radiation Exposure

Cited by 5 publications

References 34 publications

Imaging-based programming of subthalamic nucleus deep brain stimulation in Parkinson's disease

Imaging-based programming of subthalamic nucleus deep brain stimulation in Parkinson's disease

Advances in optical molecular imaging for neural visualization

Intraoperative Stereotactic Frame Registration Using a Three-Dimensional Imaging System with and without Preoperative Computed Tomography for Image Fusion

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