Bezchlibnyk Yarema B, Sharma Vibhash D, Naik Kushal B, Isbaine Faical, Gale John T, Cheng Jennifer, Triche Shirley D, Miocinovic Svjetlana, Buetefisch Cathrin M, Willie Jon T, Boulis Nicholas M, Factor Stewart A, Wichmann Thomas, DeLong Mahlon R, Gross Robert E
1Department of Neurosurgery and Brain Repair, Morsani School of Medicine, University of South Florida, Tampa, Florida.
2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.
J Neurosurg. 2020 Mar 6;134(3):1072-1082. doi: 10.3171/2019.12.JNS192010. Print 2021 Mar 1.
Deep brain stimulation (DBS) lead placement is increasingly performed with the patient under general anesthesia by surgeons using intraoperative MRI (iMRI) guidance without microelectrode recording (MER) or macrostimulation. The authors assessed the accuracy of lead placement, safety, and motor outcomes in patients with Parkinson disease (PD) undergoing DBS lead placement into the globus pallidus internus (GPi) using iMRI or MER guidance.
The authors identified all patients with PD who underwent either MER- or iMRI-guided GPi-DBS lead placement at Emory University between July 2007 and August 2016. Lead placement accuracy and adverse events were determined for all patients. Clinical outcomes were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) part III motor scores for patients completing 12 months of follow-up. The authors also assessed the levodopa-equivalent daily dose (LEDD) and stimulation parameters.
Seventy-seven patients were identified (MER, n = 28; iMRI, n = 49), in whom 131 leads were placed. The stereotactic accuracy of the surgical procedure with respect to the planned lead location was 1.94 ± 0.21 mm (mean ± SEM) (95% CI 1.54-2.34) with frame-based MER and 0.84 ± 0.007 mm (95% CI 0.69-0.98) with iMRI. The rate of serious complications was similar, at 6.9% for MER-guided DBS lead placement and 9.4% for iMRI-guided DBS lead placement (RR 0.71 [95% CI 0.13%-3.9%]; p = 0.695). Fifty-seven patients were included in clinical outcome analyses (MER, n = 16; iMRI, n = 41). Both groups had similar characteristics at baseline, although patients undergoing MER-guided DBS had a lower response on their baseline levodopa challenge (44.8% ± 5.4% [95% CI 33.2%-56.4%] vs 61.6% ± 2.1% [95% CI 57.4%-65.8%]; t = 3.558, p = 0.001). Greater improvement was seen following iMRI-guided lead placement (43.2% ± 3.5% [95% CI 36.2%-50.3%]) versus MER-guided lead placement (25.5% ± 6.7% [95% CI 11.1%-39.8%]; F = 5.835, p = 0.019). When UPDRS III motor scores were assessed only in the contralateral hemibody (per-lead analyses), the improvements remained significantly different (37.1% ± 7.2% [95% CI 22.2%-51.9%] and 50.0% ± 3.5% [95% CI 43.1%-56.9%] for MER- and iMRI-guided DBS lead placement, respectively). Both groups exhibited similar reductions in LEDDs (21.2% and 20.9%, respectively; F = 0.221, p = 0.640). The locations of all active contacts and the 2D radial distance from these to consensus coordinates for GPi-DBS lead placement (x, ±20; y, +2; and z, -4) did not differ statistically by type of surgery.
iMRI-guided GPi-DBS lead placement in PD patients was associated with significant improvement in clinical outcomes, comparable to those observed following MER-guided DBS lead placement. Furthermore, iMRI-guided DBS implantation produced a similar safety profile to that of the MER-guided procedure. As such, iMRI guidance is an alternative to MER guidance for patients undergoing GPi-DBS implantation for PD.
在全身麻醉下，外科医生越来越多地使用术中磁共振成像（iMRI）引导，在不进行微电极记录（MER）或宏观刺激的情况下进行脑深部电刺激（DBS）电极植入。作者评估了使用iMRI或MER引导，将DBS电极植入帕金森病（PD）患者内侧苍白球（GPi）时的电极植入准确性、安全性和运动结果。
作者确定了2007年7月至2016年8月期间在埃默里大学接受MER或iMRI引导的GPi-DBS电极植入的所有PD患者。确定所有患者的电极植入准确性和不良事件。对于完成12个月随访的患者，使用统一帕金森病评定量表（UPDRS）第三部分运动评分评估临床结果。作者还评估了左旋多巴等效日剂量（LEDD）和刺激参数。
共确定77例患者（MER组28例；iMRI组49例），共植入131根电极。基于框架的MER手术相对于计划电极位置的立体定向准确性为1.94±0.21mm（平均值±标准误）（95%可信区间1.54 - 2.34），iMRI为0.84±0.007mm（95%可信区间0.69 - 0.98）。严重并发症发生率相似，MER引导的DBS电极植入为6.9%，iMRI引导的DBS电极植入为9.4%（相对危险度0.71 [95%可信区间0.13% - 3.9%]；p = 0.695）。57例患者纳入临床结果分析（MER组16例；iMRI组41例）。两组在基线时具有相似特征，尽管接受MER引导的DBS患者在基线左旋多巴激发试验中的反应较低（44.8%±5.4% [95%可信区间33.2% - 56.4%] 对61.6%±2.1% [95%可信区间57.4% - 65.8%]；t = 3.558，p = 0.001）。与MER引导的电极植入（25.5%±6.7% [95%可信区间11.1% - 39.8%]）相比，iMRI引导的电极植入后改善更明显（43.2%±3.5% [95%可信区间36.2% - 50.3%]；F = 5.835，p = 0.019）。当仅在对侧半侧身体评估UPDRS III运动评分（每根电极分析）时，改善仍有显著差异（MER和iMRI引导的DBS电极植入分别为37.1%±7.2% [95%可信区间22.2% - 51.9%] 和50.0%±3.5% [95%可信区间43.1% - 56.9%]）。两组LEDDs均有相似程度的降低（分别为21.2%和20.9%；F = 0.221，p = 0.640）。所有有效触点的位置以及从这些触点到GPi-DBS电极植入共识坐标（x，±20；y，+2；z， - 4）的二维径向距离在手术类型上无统计学差异。
iMRI引导的PD患者GPi-DBS电极植入与临床结果的显著改善相关，与MER引导的DBS电极植入后的结果相当。此外，iMRI引导的DBS植入产生的安全性与MER引导的手术相似。因此，对于接受PD的GPi-DBS植入的患者，iMRI引导是MER引导的替代方法。
