Abstract
Intraoperative microelectrode recording (MER) and test-stimulation are regarded as the gold standard for proper placement of subthalamic (STN) deep brain stimulation (DBS) electrodes in Parkinson's disease (PD), requiring the patient to be awake during the procedure. In accordance with good clinical practice, most attending neurologists will request the clinically most efficacious trajectory for definite lead placement. However, the necessity of microelectrode-test-stimulation is disputed, as it may limit the access to DBS therapy, excluding those not willing or incapable of undergoing awake surgery. We retrospectively analyzed the MERs and microelectrode-test-stimulation results with regard to the decision on definite lead placement and clinical outcome in a cohort of 67 PD-patients with STN-DBS. All patients received bilateral quadripolar ring electrodes. To ascertain overall procedural efficacy, we calculated the surgical index (SI) by comparing preoperative motor improvement induced by levodopa to that induced by stimulation 7 to 18 months after surgery, measured as the relative difference between ON and OFF-states on the Unified Parkinson's Disease Rating Scale motor part (UPDRS-3). Additionally, a side-specific surgical index (SSSI) was calculated using the unilateral assessable items of the UPDRS-3. The SSSI where microelectrode-test-stimulation overruled MER were compared to those where the result of microelectrode-test-stimulation was congruent to MER results. A total of 134 electrodes were analyzed. For final lead placement, the central trajectory was chosen in 54% of patient hemispheres. The mean SI was 0.99 (± 0.24). SSSI averaged 1.04 (± 0.45). In 37 lead placements, microelectrode-test-stimulation overruled MER in the final trajectory selection, in 27 of these lead placements adverse effects during microelectrode-test-stimulation were decisive. Neither the number of test electrodes used nor the STN-signal length had an impact on the SSSI. The SSSI did not differ between lead placements with MER/microelectrode-test-stimulation congruency and those where the results of microelectrode-test-stimulation initiated lead placement in a trajectory with shorter STN signal. Intraoperative testing is mandatory to ensure an optimal motor outcome of STN DBS in PD-patients when using quadripolar ring electrodes. However, we also demonstrated that neither the length of the STN-signal on MER nor the number of test electrodes influenced the motor outcome.
Highlights
Parkinson’s disease (PD) is a progressive neurodegenerative disorder of the nigrostriatal dopaminergic system
The central trajectory was chosen in 54% of patient hemispheres
To shed further light on this important question we aimed to evaluate the impact of intraoperative microelectrode recording (MER) and microelectrode-test-stimulation on intraoperative trajectory choice for permanent lead placement and on postoperative motor performance as assessed by the Unified Parkinson’s Disease Rating Scale motor part (UPDRS-3) in a large patient cohort [11]
Summary
Parkinson’s disease (PD) is a progressive neurodegenerative disorder of the nigrostriatal dopaminergic system. It affects 100 to 200/100 000 patients and often manifests in the sixth decade of life. High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) through stereotactically implanted electrodes has been shown to improve these motor symptoms [2,3,4]. In these studies, electrodes are placed using a combination of indirect atlas-based anatomical coordinates and electrophysiological mapping of the STN including microelectrode-test-stimulation following the initial Grenoble protocol [5]. Others have shown an association between the results of intraoperative microelectrode-test-stimulation and the occurrence of motor side effects due to the unintended stimulation of the pyramidal tract [7]
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