Optimal target localization for ventroposterolateral pallidotomy: the role of imaging, impedance measurement, macrostimulation and microelectrode recording.

From October 1992 through December 1996, we performed 109 ventroposterolateral pallidotomies on 104 patients with Parkinson's disease. Throughout the series, we have used the basic imaging technique described by Laitinen, utilizing impedance measurement and macrostimulation to determine the optimal target position within with the pallidum and avoid the optic tract and the internal capsule. To take advantage of the high resolution of MR imaging while compensating for potential MR distortion, we have refined our stereotactic software to accomplish effective cross-registration and reformatting of CT and MR images. By 1995, several centers were suggesting that optimal target localization required microelectrode identification of pallidal neuronal firing patterns. During 1996, we performed microelectrode recording in 13 of the 25 patients undergoing pallidotomy. We have concluded that the basic technique of Laitinen, coupled with high-resolution imaging remains the foundation for achieving effective pallidotomy. Microelectrode recording is a useful adjunct to identify hyperactive firing patterns in the internal pallidum and, coupled with impedance measurements and macrostimulation, can define the lower border of the pallidum.