Prior to surgery, dMRI images were acquired for all patient (Ingenia 3T, Philips Healthcare, the Netherlands). Each dMRI dataset was retrieved applying 32 diffusion sensitizing gradients distributed over a half sphere with a b-value of 800 s/mm2, one b0 volume, TE 100 ms, TR 8530 ms, and a voxel size of 1.75 × 1.75 × 2 mm3. On the day of surgery, pre-operative T2 images (Fig. 1 (a)) were acquired on the same MRI system (TE 80 ms, TR 8000 ms, voxel size 0.5 × 0.5 × 2 mm3) using the Leksell® Stereotactic System (G frame, Elekta instrument AB). The T2 images were used to identify the Zi target and trajectory during preoperative planning with SurgiPlan® (Elekta Instrument AB, Sweden) (Blomstedt et al., 2012 (link)). The DBS leads were implanted in the Zi according to the clinical protocol (Wårdell et al., 2016 ) with the patients under general anaesthesia. Fluoroscopy (Philips BV Pulsera, Philips Medical Systems, the Netherlands) was used to verify position of the leads during the surgical procedure. Postoperative CT (GE Lightspeed Ultra, GE Healthcare, UK) was performed within 24 h after surgery (Fig. 1 (b)) to verify electrode position and exclude haemorrhage.
Surgiplan
Manufactured by Elekta
Sourced in Sweden
SurgiPlan is a software solution that assists clinicians in the planning and preparation of surgical procedures. It provides a platform for visualizing and analyzing patient data, such as medical images, to support the decision-making process for surgical interventions.
Automatically generated - may contain errors
Lab products found in correlation
Ge lightspeed ultra, by GE Healthcare (1 mentions)
Ingenia 3t, by Philips (1 mentions)
Bv pulsera, by Philips (1 mentions)
Activa pc, by Medtronic (1 mentions)
Leadpoint system, by Medtronic (1 mentions)
Programmable pulse generators, by Medtronic (1 mentions)
Leksell g frame, by Elekta (1 mentions)
Avanto 1.5t scanner, by Siemens (1 mentions)
Model 3389, by Medtronic (1 mentions)
7 protocols using surgiplan
1
MRI-Guided Deep Brain Stimulation Procedure
2
Deep Brain Stimulation for Neurological Disorders
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Surgery was planned using the Surgiplan (Elekta) software. The initial surgical target was defined to be 5–6 mm lateral, 12 mm superior, and 0–2 mm anterior to the midcommissural point. The mammillothalamic tract (mmt) and ANT nucleus were identified individually from the 3T MRI and the surgical target was adjusted accordingly (13 (link)). A transventricular trajectory was performed primarily (26/32) with the secondary option being the paraventricular trajectory which was chosen in cases where there were abundant ventricular veins (6/32). Under general anesthesia, the surgery was performed using insertion cannula reaching to 10 mm from the planned target to implant the DBS electrodes (Medtronic 3389). The electrodes were fixed to the skull and connected to extension cables and further to the internal pulse generator (Activa PC, Medtronic) implanted within a subcutaneous pocket in the upper chest area.
The DBS was turned on in the fifth postoperative day. Stimulation was programmed to a cycle of 1 min ON and 5 min OFF with a frequency of 140 Hz and a pulse width of 90 µs. The amplitude was increased to 5 V during the first weeks of stimulation. The initially chosen contacts were changed if necessary due to nonresponsiveness or adverse effects.
The DBS was turned on in the fifth postoperative day. Stimulation was programmed to a cycle of 1 min ON and 5 min OFF with a frequency of 140 Hz and a pulse width of 90 µs. The amplitude was increased to 5 V during the first weeks of stimulation. The initially chosen contacts were changed if necessary due to nonresponsiveness or adverse effects.
3
Stereotactic Deep Brain Stimulation Procedure
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The surgical procedure was similar to that reported in previous studies [13 (link), 14 (link)]. Anti-Parkinsonian medications were not stopped preoperatively. A stereotactic Leksell G frame (Elekta) was mounted on the head under local anesthesia. A 1.5 T brain MRI was performed (General Electric Medical Systems). The 3-D fast spoiled gradient-echo (FSPGR) sequence was used for anterior commissure (AC)–posterior commissure (PC) calculations. T2 spin-echo images were obtained to define the boundaries of the STN. SurgiPlan (Elekta) was used to run the simulations for targeting the sensorimotor region of the STN and selecting the trajectories. MERs were performed by means of a Leadpoint system (Medtronic) under general anesthesia. The depth of sedation was monitored by the bispectral index under total intravenous anesthesia with propofol and remifentanil. The propofol concentration was titrated to maintain the bispectral index value of 60–80. Permanent model 3389 (Medtronic) quadripolar electrodes were implanted along the proper trajectory to stimulate more sensorimotor regions of the STN, which was localized by both preoperative brain MRI and intraoperative MER. Left DBS was performed first, followed by right DBS. Programmable pulse generators (Medtronic) were implanted in the subclavicular region and connected to the electrodes.
4
Deep Brain Stimulation Surgery Protocol
5
Ventral Anterior Limb Bilateral DBS Implantation
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Patients were bilaterally implanted under general anesthesia, according to standard stereotactic procedures. Surgical planning was performed based on anatomical landmarks in SurgiPlan (Elekta AB, Stockholm, Sweden), such that the active DBS contacts (model 3389, Medtronic, Minneapolis, US; 4x 1.5 mm contacts with 0.5 mm interspace) were placed in the ventral anterior limb of the internal capsule (ALIC) (van den Munckhof et al., 2013 (link)). The electrodes were coronally angled to follow the ALIC trajectory with an approximate anterior angle of 75°. Correct lead placement was ensured with co-registration of postoperative computed tomography (CT) to preoperative structural MRI.
6
Stereotactic Anterior Capsulotomy Protocol
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The stereotactic procedure was performed with a Leksell Stereotactic system model G and planning software SurgiPlan (version Elekta Instruments, Stockholm, Sweden). MRI was performed on a Siemens Avanto 1.5 T scanner (Siemens, Munich, Germany), and included a 3D FLASH, T1‐weighted sequence (1.3 mm slice thickness), T2 SE, and PD‐weighted sequences (2 mm slice thickness). Intravenous contrast medium was applied to avoid intracranial vessels.
The anterior limbs of the internal capsule were chosen as the target for the ablative procedure in the vicinity of the anterior commissure with coordinates adjusted according to individual brain anatomy imaged by MRI: X = 11–19 mm from the midline; Y = 4–10 mm anterior to the anterior commissure; Z = 2–4 mm superior to the anterior–posterior commissure line.
The anterior limbs of the internal capsule were chosen as the target for the ablative procedure in the vicinity of the anterior commissure with coordinates adjusted according to individual brain anatomy imaged by MRI: X = 11–19 mm from the midline; Y = 4–10 mm anterior to the anterior commissure; Z = 2–4 mm superior to the anterior–posterior commissure line.
7
Stereotactic Targeting of Nucleus Accumbens
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3T MRI scans were made to assess surgical eligibility at baseline. On the morning of surgery, a stereotactic frame was attached to the patient's head under general anesthesia, before scanning the patient in a 1.5T MRI scanner. Surgical planning was performed according to standard stereotactic procedures described in detail by Van den Munckhof and colleagues [5] (link). In short, the 3T scan and stereotactic 1.5T scan were co-registered with SurgiPlan (Elekta AB, Stockholm, Sweden) to enable planning in the stereotactic space. Target planning started with standard stereotactic coordinates relative to intercommissural line: 7 mm lateral of the midline, 3 mm anterior to the anterior border of the anterior commissure, and 4 mm inferior to the intercommissural line. Target planning was subsequently optimized, i.e, direct target planning based on representation of the nucleus accumbens and ALIC, in such way that the deepest contact of the quadripolar electrode (contact 0) was targeted in the nucleus accumbens and the upper three contacts (contacts 1e3) in the vALIC. Target coordinates were expressed in stereotactic space. Electrodes (model 3389 with 1.5 mm contacts and 0.5 mm interspace, Medtronic, Minneapolis, MN, USA) were implanted bilaterally with a sagittal angle of ±75 to the intercommissural line, and a coronal angle approximately following the ALIC into the NAc.
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