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Dr. Okun

Post of the Week: DBS in the MRI Suite

8 posts in this topic

Dear forum members,

 

We have been following the evolving story on a new system for doing DBS in the MRI suite (not the OR). Below are the results of an experiment showing it could be pretty accurate. We will keep you posted on testing.

 

 

Neurosurgery. 2011 Jul 25. [Epub ahead of print]

An Optimized System for Interventional MRI Guided Stereotactic Surgery: Preliminary Evaluation of Targeting Accuracy.

Larson PS, Starr PA, Bates G, Tansey L, Richardson RM, Martin AJ.

Source

1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA; 2SurgiVision, Inc, Irvine, CA, USA; 3Department of Radiology, University of California, San Francisco, San Francisco, CA, USA.

Abstract

BACKGROUND:

Deep brain stimulation (DBS) electrode placement using interventional MRI has been previously reported using a commercially available skull mounted aiming device (Medtronic Nexframe MR) and native MRI scanner software. This first-generation method has technical limitations that are inherent to the hardware and software used. A novel system (SurgiVision ClearPoint) consisting of an aiming device (SMARTFrame) and software has been developed specifically for iMRI interventions including DBS.

 

OBJECTIVE:

A series of phantom and cadaver tests were performed to determine the system's capability, preliminary accuracy and workflow.

 

METHODS:

18 experiments using a water phantom were used to determine predictive accuracy of the software. 16 experiments using a gelatin-filled skull phantom were used to determine targeting accuracy of the aiming device. 6 procedures in three cadaver heads were performed to compare workflow and accuracy of ClearPoint with Nexframe MR.

 

RESULTS:

Software prediction experiments showed an average error of 0.9±0.5 mm in magnitude in pitch and roll (mean pitch error -0.2±0.7 mm, mean roll error +0.2±0.7 mm) and an average error of 0.7±0.3 mm in X-Y translation with a slight anterior (0.5±0.3 mm) and lateral (0.4±0.3mm) bias. Targeting accuracy experiments showed average radial error of 0.5±0.3 mm. Cadaver experiments showed a radial error of 0.2±0.1 mm with the ClearPoint system (average procedure time 88±14 minutes) vs 0.6±0.2 mm with the Nexframe MR (average procedure time 92±12 minutes).

 

CONCLUSION:

This novel system provides the submillimetric accuracy required for stereotactic interventions including DBS placement. It also overcomes technical limitations inherent in the first-generation iMRI system.

Michael S. Okun, M.D.

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Dear Dr. Okun,

 

I am trying to compare the interventional MRI for DBS as depicted in your august 14, 2011 report of a study to measure its accuracy versus what I interpret is has started to be applied at John Hopkins and the Cleveland Clinic, which unlike the UCSF approach is not a real time MRI because the OR does not move to the MRI suite, but and intermitent MRI which can be used many times during the surgery, in other words, it is used as needed instead.

 

In both approaches the patient is asleep but if believe the USCF is less risky for bleeding but not for infections and I have no clue about accuracy of one vs the other. Could you comment on pros and cons of those approaches, since I had been advised to undergo DBS and have been evaluated as ideal for the dtandard procedure, in which I would have to be awake?

 

Thanks a lot,

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At the moment the most important thing is not the presence or absence of MRI in or out of the operating room. The most important is the presence of an expert team that will perform true physiological mapping (microelectrode reording) and testing of the DBS lead before you leave the OR. Most experienced teams can image the structures well before you even enter the operating room--these cool new toys do not necessarily improve the quality of the outcome. In fact some may argue the reverse as they try to shave minutes off the procedure. The bottom line I would say is to choose an experienced team!

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At the moment the most important thing is not the presence or absence of MRI in or out of the operating room. The most important is the presence of an expert team that will perform true physiological mapping (microelectrode reording) and testing of the DBS lead before you leave the OR. Most experienced teams can image the structures well before you even enter the operating room--these cool new toys do not necessarily improve the quality of the outcome. In fact some may argue the reverse as they try to shave minutes off the procedure. The bottom line I would say is to choose an experienced team!

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Dear Dr. Okun,

 

Agreed. I could say that I have already a terrific team tentatively assembled in two competing sites. But how much does the technology will improve the outstanding performance of a great team under a continuous interventional MRI (UCSF, the OR goes into the MRI suite) versus an intermitent interventional MRI (The MRI goes into the OR). Specifically, which technology will improve more my odds of accuracy(+), bleeding(-) and infection(-)?

 

Thanks a lot for trying to answer such a difficult question because of dealing with such new approaches.

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There is no comparison data available,

 

Just be aware if they use no microelectrode recording or less recording it MAY potentially impact outcome.

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How long does someone with parkinsons disease live to be?

 

Is parkinsons Disease fatal. My mom has had it for about 20 years and she is 54 now. How much longer will she live and what will happen to her. She had the brain surgery 5 years ago and it's not working any more. Please help.

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First, take her to an expert center and be sure the brain surgery was done correctly and is functioning properly. The surgery does not prevent disease progression, but there are lasting benefits on tremor, dyskinesia, on-off fluctuations and other issues. The benefits depend patient to patient....

 

Finally, PD is a mystery as many people can live 20+ years and do very well under great medical treatment. We don't have a way to predict who those PD patients will be!

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