To categorize the neuroanatomical location of stimulation, we determined the location of the center of the active electrode contact (when multiple contacts were used, the interspace between active contacts was determined) on postoperative CT (1 or 2 mm slice thickness) coregistered with the preoperative magnetic resonance using Leksell Surgiplan (Elekta). The center of stimulation was classified as "VIM" when the active contact(s) were localized in or just below (=touching) the ventral thalamic border on T2-weighted coronal MRI, and as "PSA" when active contacts were localized deeper.
Leksell surgiplan
Manufactured by Elekta
Sourced in Sweden, United States
Leksell SurgiPlan is a medical software system designed for planning and simulating neurosurgical procedures. It provides healthcare professionals with tools to visualize and analyze patient anatomy, plan surgical approaches, and simulate outcomes.
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9 protocols using leksell surgiplan
1
Neuroanatomical Localization of DBS
2
Leksell Vantage System Coordinate Conversion
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A significant difference from the classic method is that the Leksell Vantage Z-scale on both sides is reversed and mounted. Therefore, it is necessary to convert the existing coordinate calculation method. The study by Horisawa et al. [9 (link)] explains the principle of correcting the Z value for this method. We refer to this report to make it simpler.
First, the [X, Y, Za, Arc0, Ringa0] coordinates of target points can be calculated using Leksell SurgiPlan® software (Elekta, Stockholm, Sweden), with arc 00 located on the patient’s right side (Fig. 3A ). Fig. 3B explains the calibration. In the program, the upper and lower values of the Leksell vantage Y scale are fixed at absolute values of 168 and 192, respectively. Using this, even when the phase is inverted, the distance from the center of the Z scale ring to the Y scale is the same (Da=Db). This distance is always the same for any arbitrary target. Accordingly, the conversion expression of the Z coordinate (Za : Z coordinate on Leksell SurgiPlan®, Zb : Z coordinate calibration for operation target) Da=Db; 168–Za=Zb–192; Zb=360–Za can be obtained.
Using this conversion, we converted the coordinates obtained from the program to [X, Y, Zb=360–Za, Arc0, Ringb0=Ringa0–1800]. The calculated arc0 using Leksell SurgiPlan® remained the same, but the Ringb0 was calculated by subtracting 1800 from Ringa0.
First, the [X, Y, Za, Arc0, Ringa0] coordinates of target points can be calculated using Leksell SurgiPlan® software (Elekta, Stockholm, Sweden), with arc 00 located on the patient’s right side (
Using this conversion, we converted the coordinates obtained from the program to [X, Y, Zb=360–Za, Arc0, Ringb0=Ringa0–1800]. The calculated arc0 using Leksell SurgiPlan® remained the same, but the Ringb0 was calculated by subtracting 1800 from Ringa0.
3
Stereotactic Biopsy Procedure for CNS Tumors
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Tissue samples were immediately fixed in 10% formalin solution and sent to the Pathology Department, where they were processed the same day or the day after in cases in which the procedures were performed in the late afternoon. Histopathological diagnosis was performed according to the 2016 WHO classification of CNS tumours [45 (link)]. In cases of stereotactic biopsy, the procedure began with fixation of the patient’s skull in the MRI-compatible Leksell stereotactic frame (Model G, Elekta, Stockholm, Sweden). During the procedure, a Sedan biopsy needle (10 mm needle window, 2.5 mm diameter) was used to acquire at least two cylindrical tissue biopsies, based on the macroscopical aspect, size of the sample, and procedure-related risks. The bioptic sampling accuracy was eventually confirmed via co-registering the postoperative CT images with preoperative imaging and the planned trajectory in the Leksell SurgiPlan® (Elekta Instruments AB, Stockholm, Sweden) software for all cases in the series. The stereotactic coordinates of the exact, final sites of biopsy were exported from the Surgiplan software and transferred to VERDICT maps using the transformations obtained when registering the T1-weighted images to dMRIs.
4
Stereotactic Guidance for Deep Brain Stimulation
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Preoperatively, the location of the GPi was determined using a stereotactic computed tomography (CT) scan [with the Leksell (Elekta, Inc.) head frame] coregistered to high-resolution 3.0 T T1- and T2-weighted magnetic resonance imaging (MRI) images with Leksell SurgiPlan (Elekta, Stockholm, Sweden). In general, the target was defined directly under the guidance of coregistered image and the location was about 2–4 mm anterior to the midpoint of the anterior commissure–posterior commissure line (AC–PC), 18–22 mm lateral to the AC–PC line, and 2–4 mm below the AC–PC line. The procedure was performed under general anesthesia. After confirmation of location of the electrodes (Model 3387, Medtronic, Inc., Minneapolis, MN, USA; or Model L302, PINS, Inc., Beijing, China) with intraoperative CT, the impulse generator was implanted. A CT or MRI scan was performed 1 week after the surgery to confirm the location of the electrodes.
5
Delineation and Targeting of Anterior Nucleus of Thalamus
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All images were analyzed using Leksell SurgiPlan software (Elekta AB, Stockholm, Sweden). At first, midpoints of the anterior commissure–posterior commissure (AC–PC) line were defined in the 3D-T1-weighted images. Next, a co-registration of STIR and 3D-T1 contrast images was performed. Stereotactic coordinates relative to the mid-commissural point (MCP) of the points along the delineated borders of the ANT in the coronal and sagittal orientations were collected. Thereafter, a cross-sectional model of ANT was calculated in the sagittal and coronal orientations and plotted onto an AC–PC based coordinate system. These delineations were also used for measurements of length, height, width and cross-sectional area of the ANT in each thalamus (Table 1 ). To study anatomical overlap between individuals in stereotactic space, each anatomical model was taken into a common AC–PC based coordinate system. The degree of anatomical overlap was expressed as overlapping area (mm2, Fig. 3 ) as a function of the number of patients. Targeting for implantation was performed by using AC–PC based coordinates as a starting point and adjusting the target directly from the images to account for anatomical variations.
6
Localization of Implanted Brain Contacts
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For all patients, both a structural pre-operative MRI scan and an intra-operative computed tomography (CT) scan were acquired as part of the clinical routine. We used the co-registration between the MRI and CT information, obtained within the Leksell SurgiPlan software (Elekta, Stockholm, Sweden). Visual inspection of the fused images allowed the precise localization of every contact within each patient's anatomy. These locations were then visually classified by the neurologist on the basis of a human brain atlas (Mai et al., 2008) , with only minor modifications to its parcellation. The lateral basal and temporal regions, as well as the medial cingular areas, were divided into anterior, middle and posterior subregions. These subdivisions were intended to capture relevant functional distinctions made in Price's (2012) review of functional-imaging studies of language. Finally for visualization purposes, all patients' contacts were mapped onto a common parcellated brain template (ICBM152), as implemented in Brainstorm (Tadel et al., 2011) . The parcels were either adapted from the predefined Destrieux and Desikan-Killiany atlases in Brainstorm, or created from Brainstorm's user interface.
7
High-resolution MRI-Guided DBS Targeting
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High-resolution magnetic resonance imaging (MRI, 3.0 T, General Electric Company, USA) and Leksell SurgiPlan (Elekta, Stockholm, Sweden) were used for targeting the HB in each patient’s brain. From each patient, we obtained T1 maps, proton spin-density maps, R2* maps, and quantitative susceptibility maps. Using the patient’s high-resolution T1-weighted MRI images, we were able to delineate the HB clearly in the axial view. The target site was located about 0–2 mm in front of the posterior commissure, 3–5 mm lateral, and 0–1 mm above the anterior commissure–posterior commissure.
Both quadripolar DBS electrodes (model 3389, Medtronic, Minneapolis, MN, USA; or 1210-40, SceneRay, Suzhou, China) and the pulse generator (37603 SC, Medtronic; or 1180, SceneRay) were implanted under general anesthesia. DBS electrode contacts had a length of 1.5 mm and a diameter of 1.27 mm, and the spacing between contacts was 0.5 mm. DBS parameters used for each patient are listed in Supplementary Table1 . The DBS programming procedure we followed has been described by Bergfeld et al. [8 (link)].
Both quadripolar DBS electrodes (model 3389, Medtronic, Minneapolis, MN, USA; or 1210-40, SceneRay, Suzhou, China) and the pulse generator (37603 SC, Medtronic; or 1180, SceneRay) were implanted under general anesthesia. DBS electrode contacts had a length of 1.5 mm and a diameter of 1.27 mm, and the spacing between contacts was 0.5 mm. DBS parameters used for each patient are listed in Supplementary Table
8
Stereotactic Thalamic Lesioning for Tremor
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Stereotactic planning was performed using the Leksell SurgiPlan (Elekta, Stockholm, Sweden) and BrainLab Elements (BrainLab, Munich, Germany). Stereotactic target of the Vim nucleus of the thalamus was set 12.5–15 mm lateral from the midline or 11–12 mm lateral from the third ventricle wall, 4–6 mm anterior from the posterior commissure (PC), and on the anterior commissure (AC)–PC (AC–PC) plane. The surgery was performed under local anesthesia. Microelectrode recordings were not used. We used a monopolar radiofrequency probe (1.0‐mm‐diameter tip with 4.0 mm uninsulated length) and Leksell Neuro Generator (Elekta) for macrostimulation (130 Hz, 100‐μs pulse width, up to 4.3 mA) and coagulation. Coagulation was performed at 70°C for 40 s at the tentative target, and the electrode was withdrawn in 3‐mm increments to increase the lesion size, resulting in two contiguous lesions. We also added similar lesions 3 mm anteromedial to the target, which corresponded to the posterior part of the ventro‐oral (Vo) nucleus (Vop). Before coagulation, we performed macrostimulation to carefully assess for tremor improvement and side effects (sensory and capsular responses). Within 24 h of surgery, a postoperative magnetic resonance imaging (MRI) was performed to confirm the location of the lesion (Fig. 1 ).
9
Stereotactic Pallidothalamic Tract Ablation for Parkinson's
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Leksell SurgiPlan (Elekta) was used to plan the stereotactic targets and electrode trajectory. Unilateral PTT was performed on the side most affected by parkinsonian motor symptoms. With the patient under local anesthesia, a Leksell stereotactic frame (Elekta) was fixed to their head. Axial (1-mm slice) T1-weighted and axial (1-mm slice) and coronal (2-mm slice) T2-weighted MR images were used to plan the PTT surgery. The lateral part of the pallidothalamic tract is long and corresponds to the thalamic fasciculus on Morel's atlas. According to Morel's atlas, the width of the pallidothalamic tract is 6 mm at the anterior commissure-posterior commissure (AC-PC) plane. Therefore, we set two stereotactic ablative targets to cover the pallidothalamic tract (Fig. 1). The medial target was set at 8-10 mm lateral and 0.5-2.5 mm inferior to the midpoint of the AC-PC and at the midpoint of the AC-PC. The lateral target was set at 10-13 mm lateral, 1.0-2.0 mm inferior, and 1 mm posterior to the midpoint of the AC-PC. A monopolar radiofrequency electrode (1.0-mm-diameter tip with an uninsulated length of 2.0-4.0 mm) and a Leksell Neuro Generator (Elekta) were used to perform macrostimulation (130 Hz, 100-µsec pulse width, up to 5 mA) and ablation. Before ablation, macrostimulation was performed to confirm adverse effects. A single ablation at 70°C for 40 seconds was made at each target.
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