• World Neurosurg · Dec 2016

    Case Reports

    A Case Study of Image-Guided Deep Brain Stimulation: MRI-Based White Matter Tractography Shows Differences in Responders and Non-Responders.

    • Rafael L O'Halloran, Alexander G Chartrain, Jonathan J Rasouli, Ritesh A Ramdhani, and Brian Harris Kopell.
    • Department of Radiology, Mount Sinai Hospital, New York, New York, USA; Department of Psychiatry, Mount Sinai Hospital, New York, New York, USA.
    • World Neurosurg. 2016 Dec 1; 96: 613.e9-613.e16.

    BackgroundThe caudal zona incerta (cZI) is an increasingly popular deep brain stimulation (DBS) target for the treatment of tremor-predominant disease. The dentatorubrothalamic tract (DRTT) is a white matter fiber bundle that traverses the cZI and can be identified using diffusion-weighted magnetic resonance imaging fiber tractography to ascertain its precise course. In this report, we compare 2 patient cases of cZI DBS, a responder and a nonresponder.Case DescriptionPatient 1 (responder) is a 65-year-old man with medically refractory Parkinson disease who underwent bilateral DBS lead placement in the cZI. Postoperatively he demonstrated >90% reduction in baseline tremor and was not limited by stimulation side effects. Postoperative imaging showed correct lead placement in the cZI. Tractography revealed a DRTT within the field of stimulation, bilaterally. Patient 2 (nonresponder) is a 61-year-old man with medically refractory Parkinson disease who also underwent bilateral DBS lead placement in the cZI. He initially demonstrated >90% reduction in baseline tremor but developed disabling dystonia of his left leg and significant slurring of his speech in the months after surgery. Postoperative imaging showed bilateral lead placement in the cZI. Right-sided electrode revision was recommended and resulted in relief of tremor and reduced dystonic side effects. Tractography analysis of the original leads revealed a DRTT with an atypical anterior trajectory and a location outside the field of stimulation. Tractography analysis of the revised lead showed a DRTT within the field of stimulation.ConclusionsPreoperative diffusion-weighted magnetic resonance imaging fiber tractography imaging of the DRTT has the potential to improve and individualize DBS planning.Copyright © 2016 Elsevier Inc. All rights reserved.

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