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      Does trajectory matter? A study looking into the relationship of trajectory with target engagement and error accommodation in subthalamic nucleus deep brain stimulation

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          Abstract

          Background

          Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is now a key treatment choice for advanced Parkinson’s disease. The optimum target area within the STN is well established. However, no emphasis on the impact of trajectory exists. The ellipsoid shape of the STN and the off-centre traditional target point mean that variation in the electrode inclination should affect STN engagement. Understanding of this relationship could inform trajectory selection during planning by improving STN engagements and margins for error.

          Method

          We simulated electrode placement at the clinical target through a set of trial trajectories. Twelve three-dimensionally reconstructed STNs were created from magnetic resonance imaging data of six patients. An appropriate target within each STN was then chosen. Each STN was approached through 56 simulated trajectories arranged in a grid covering a quadrant of skull around and in front of the coronal suture. A subset of 20 viable trajectories was reassessed for depth of engagement in each STN whilst approaching the chosen target.

          Results

          Group averages for each trajectory are presented as traffic light maps and as an overlaid skull mask illustrating recommended electrode entry sites. Trajectories under 30 degrees anterior to the bregma and between 10 to 30 degrees off the midline accommodated over 2.4 degrees of wobble. A mean engagement of 6 mm was possible in half of the subset. The longest engagements are on trajectories which saddle the coronal suture, extending to 40 degrees lateral. Microelectrode tracts of 14 additional STNs were collated using the above protocol and engagement exceeded 5 mm in all central trajectories without capsular side effects, suggesting placement away from STN borders.

          Conclusions

          Trajectory selection influences engagement and flexibility to accommodate electrode wobble or brain shift whilst approaching a chosen STN target. We recommend having the first trial trajectory 20 degrees anterior to the bregma, moving postero-laterally in successive trials to balance both error and engagement. When wider margins for error are beneficial (e.g. second side during bilateral procedures), trajectories nearer the coronal suture and around 25 degrees off the midline are advised.

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          Most cited references4

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          Brain shift during bur hole-based procedures using interventional MRI.

          OBJECT.: Brain shift during minimally invasive, bur hole-based procedures such as deep brain stimulation (DBS) electrode implantation and stereotactic brain biopsy is not well characterized or understood. We examine shift in various regions of the brain during a novel paradigm of DBS electrode implantation using interventional imaging throughout the procedure with high-field interventional MRI.
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            The impact of brain shift in deep brain stimulation surgery: observation and obviation.

            The impact of brain shift on deep brain stimulation surgery is considerable. In DBS surgery, brain shift is mainly caused by CSF loss. CSF loss can be estimated by post-surgical intracranial air. Different approaches and techniques exist to minimize CSF loss and hence brain shift. The aim of this survey was to investigate the extent and dynamics of CSF loss during DBS surgery, analyze its impact on final electrode position, and describe a simple and inexpensive method of burr hole closure.
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              Minimizing brain shift during functional neurosurgical procedures - a simple burr hole technique that can decrease CSF loss and intracranial air.

              Exact stereotactic placement of deep brain stimulation electrodes during functional stereotactic neurosurgical procedures can be impeded by intraoperative brain shift. Brain shift has been shown to correlate with the amount of intracranial (subdural) air detected on early postoperative imaging studies. We report a simple burr hole technique that reduces the loss of cerebrospinal fluid (CSF) and has the potential to significantly reduce the amount of postoperative intracranial air.
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                Author and article information

                Contributors
                davidasteel@gmail.com
                Journal
                Acta Neurochir (Wien)
                Acta Neurochir (Wien)
                Acta Neurochirurgica
                Springer Vienna (Vienna )
                0001-6268
                0942-0940
                30 March 2017
                30 March 2017
                2017
                : 159
                : 7
                : 1335-1340
                Affiliations
                [1 ]ISNI 0000 0004 1936 8868, GRID grid.4563.4, , University of Nottingham Medical School, ; Nottingham, UK
                [2 ]ISNI 0000 0001 0440 1889, GRID grid.240404.6, Department of Neurosurgery, , Nottingham University Hospitals, ; Nottingham, UK
                Article
                3151
                10.1007/s00701-017-3151-y
                5486602
                28361249
                26cf1cd7-0c22-47b6-a480-31a16de01974
                © The Author(s) 2017

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 18 November 2016
                : 13 March 2017
                Funding
                Funded by: University of Nottingham
                Categories
                Original Article - Functional
                Custom metadata
                © Springer-Verlag GmbH Austria 2017

                Surgery
                deep brain stimulation,parkinson’s disease,subthalamic nucleus,targeting,trajectory
                Surgery
                deep brain stimulation, parkinson’s disease, subthalamic nucleus, targeting, trajectory

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