Division of Stereotaxy and MR-based Operative Techniques/Department of Neurosurgery, University of Bonn, Sigmund Freud Straße 25, 53105 Bonn, Germany.
Acta Neurochir (Wien). 2011 Aug;153(8):1579-85; discussion 1585. doi: 10.1007/s00701-011-1036-z. Epub 2011 May 8.
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.
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.
Three months after implantation, tremor control was excellent (>90%). A close evaluation of the active electrode contact positions revealed clear involvement of the drt.
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.
深部脑刺激（DBS）可减轻各种来源的震颤。许多区域是靶向的。在最近的工作中，我们的团队能够通过纤维跟踪技术显示齿状红核丘脑束（drt）在震颤控制中的参与。在这里，我们首次报告了磁共振束追踪技术与传统基于地标定位技术相结合，成功应用于一名肌张力障碍性头部震颤患者双侧 DBS 系统植入。
我们报告了一名 37 岁女性，患有长期单纯头部震颤的肌阵挛性 dystonia。她被确定为丘脑 DBS 的候选者。由于手术过程中头部固定在立体定向框架中会使目标症状（头部震颤）模糊，因此避免了这种情况。她的齿状核红核丘脑束在术前弥散张量成像（DTI）和束追踪中被可视化，然后直接通过 DBS 电极进行立体定向靶向。
植入后 3 个月，震颤控制效果极佳（>90%）。对活性电极接触位置的仔细评估显示，drt 明显参与。
这是首次直接可视化纤维束用于直接靶向和成功的运动障碍震颤手术。在报告的病例中，对 drt 位置的额外了解，先前已表明该结构是用于调制以实现震颤控制的结构，导致 DBS 系统的成功植入，尽管术中没有可测试的震颤症状。与光遗传神经调节研究一致，纤维束是 DBS 的新兴目标结构。将 DTI 束追踪常规整合到手术计划中可能是 DBS 手术未来的一个主要方向，并将有助于我们对运动障碍生理病理学的理解。更大的研究人群将不得不通过未来的研究来证明这些概念。
