title: Subthalamic nucleus stimulation for advanced Parkinson's disease: how to find a far medial STN.
abstract: In a patient with advanced Parkinson's disease, an anatomically deviant far medial subthalamic nucleus (STN) posed problems in the placement of DBS electrodes for chronic high frequency (HF) stimulation despite the use of multimodal targeting with 1) statistical atlas data, 2) T (2)-weighted (T (2)W) magnetic resonance imaging (MRI), 3) microelectrode recording, and 4) clinical testing with macro stimulation. Diagnostic T (2)W MRI suggested that the patient's STN was in a typical location and seemed to confirm the statistical atlas-based planning. Intraoperatively, cell activity recording (MER) with five parallel electrodes could not reveal any STN typical activity profile and electrical stimulation was not able to disclose a medial or lateral displacement of the electrodes. The operation was discontinued and postoperative stereotactic CT confirmed that the correct target area had been approached during the operation. Postoperative T (2)W MRI now disclosed a left STN which was 2 mm medial of the initial target and lead to a further medial target definition and finally to a successful DBS placement. In conclusion, finding a deep seated DBS target like the STN can be difficult in cases with an extremely deviant anatomy even if reiterative sophisticated multimodal planning is used. In the presented case we applied the integrated information from intraoperative MER, macrostimulation and postoperative imaging work-up and were able to complete DBS implantation successfully.
authors.affiliation: Department of Neurosurgery, University Hospital of the Aachen University (RWTH), Pauwelsstrasse 30, 52057 Aachen, Germany. vacoenen@aol.com
authors.forename: V A
authors.initials: VA
authors.lastname: Coenen
authors.forename: F
authors.initials: F
authors.lastname: Gielen
authors.forename: I
authors.initials: I
authors.lastname: Rohde
authors.forename: C
authors.initials: C
authors.lastname: Fromm
authors.forename: M
authors.initials: M
authors.lastname: Kronenbürger
authors.forename: S
authors.initials: S
authors.lastname: Dammert
authors.forename: V
authors.initials: V
authors.lastname: Rohde
mesh_terms: D001931:Brain Mapping / Q000379:methods*; D046690:Deep Brain Stimulation; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D010300:Parkinson Disease / Q000628:therapy*; D012086:Reoperation; D013238:Stereotaxic Techniques; D020531:Subthalamic Nucleus / Q000033:anatomy & histology* / Q000503:physiopathology / Q000601:surgery*; D014057:Tomography, X-Ray Computed