震颤症患者在规划立体定向手术时齿状突触丘脑束的个体差异性

A. Kholyavin, A. V. Peskov, A. O. Berger
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The aim of the work is to study the variability of the position of the dentato‑rubro‑thalamic tract (DRT), determined according to MRI tractography data, in relation to the main reference points for indirect stereotactic guidance, as well as to the visible landmarks on MRI in FGATIR mode, to assess the validity of the currently used methods of preparing operations in patients with tremor.Materials and methods. Probabilistic MRI tractography of DRT based on the HARDY protocol was performed in 34 patients. Additionally, 3D T1 tomograms were obtained with axial slices with an isotropic voxel size equal to 1 mm, as well as FLAIR sagittal slices with a thickness of 1.12 and a pitch of 0.56 mm. Eleven patients additionally underwent a series of MRI sections according to the FGATIR program with a thickness of 1 mm, without an intersectional gap.Results. 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引用次数: 0

摘要

背景。丘脑腹中核(Vim)和丘脑后区(PSA)的立体定向手术用于震颤的外科治疗。由于在标准磁共振成像(MRI)系统中看不到这些结构,因此在手术过程中主要采用间接立体定向引导。磁共振成像束成像可以考虑震颤目标结构的个体差异,直接观察目标,但这项技术尚未进入准备手术的常规实践中。这项工作的目的是研究根据核磁共振成像束成像数据确定的齿状丘脑束(DRT)位置与间接立体定向引导的主要参考点以及 FGATIR 模式核磁共振成像上的可见地标之间的可变性,以评估目前使用的震颤患者手术准备方法的有效性。根据 HARDY 方案对 34 名患者进行了 DRT 的概率 MRI 牵引成像。此外,还获得了各向同性体素大小等于 1 毫米的轴向切片三维 T1 层析成像图,以及厚度为 1.12 毫米、间距为 0.56 毫米的 FLAIR 矢状切片。此外,11 名患者还根据 FGATIR 程序进行了一系列厚度为 1 毫米、无交叉间隙的核磁共振切片检查。无论是在前后神经束坐标系中,还是在与间接立体定向引导的标准目标的关系中,DRT位置都存在明显的可变性。此外,研究还发现,大脑半球之间的神经束位置存在明显的不对称性。在红核最大直径水平的尾状突起区(cZI)植入的脑深部刺激电极的轨迹偏离束的程度最小。在 FGATIR 模式下的断层扫描中,也确定了该束与前叶放射靶区(Raprl)之间的高度对应性。在 PSA 中间接瞄准 Vim 靶点和脑小脑束的标准靶点与 DRT 的偏差在近一半的患者中超过 2 毫米。在使用 cZI 作为治疗震颤的间接引导标准靶点时,76.5% 的病例的 DRT 位于电极第 2 或第 3 次接触水平的立体定向冲击区。通过 FGATIR 模式可以观察到 Raprl 的结构,在 86.4% 的病例中可以通过立体定向引导对 DRT 产生效果。
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The individual variability of the dentato-rubro-thalamic tract in the planning of stereotactic operations in patients with tremor
Background. Stereotactic operations on the ventral‑intermediate nucleus of the thalamus (Vim) and the posterior subthalamic area (PSA) are used for the surgical treatment of tremor. Since these structures are invisible in standard magnetic resonance imaging (MRI) regimes, indirect stereotactic guidance is mainly used during operations. MRI tractography allows taking into account the individual variability of the target structures for tremor, visualizing the target directly, but this technique has not yet entered the routine practice of preparing operations.Aim. The aim of the work is to study the variability of the position of the dentato‑rubro‑thalamic tract (DRT), determined according to MRI tractography data, in relation to the main reference points for indirect stereotactic guidance, as well as to the visible landmarks on MRI in FGATIR mode, to assess the validity of the currently used methods of preparing operations in patients with tremor.Materials and methods. Probabilistic MRI tractography of DRT based on the HARDY protocol was performed in 34 patients. Additionally, 3D T1 tomograms were obtained with axial slices with an isotropic voxel size equal to 1 mm, as well as FLAIR sagittal slices with a thickness of 1.12 and a pitch of 0.56 mm. Eleven patients additionally underwent a series of MRI sections according to the FGATIR program with a thickness of 1 mm, without an intersectional gap.Results. A significant variability of the DRT position has been established both in the coordinate system of the anterior and posterior commissures, and in relation to standard targets for indirect stereotactic guidance. In addition, a visible interhemispheric asymmetry of the position of the tracts was revealed. The smallest degree of deviation from the tract was noted for the trajectories of deep brain stimulation electrodes implanted in the caudal zona incerta (cZI) at the level of the maximum diameter of the red nuclei. A high degree of correspondence between the tract and the target zone of prelemniscal radiations (Raprl) was also established on tomograms in the FGATIR mode.Conclusions. The standard target points for the indirect targeting of Vim targets and the cerebello‑thalamic tract in PSA give a deviation of more than 2 mm from DRT in almost half of patients. During the use of cZI as a standard target for indirect guidance in the treatment of tremor, the DRT is located at the zone of stereotactic impact at the level of the 2nd or 3rd contact of the electrode in 76.5 % of cases. FGATIR mode allows visualizing the structure of Raprl, with stereotactic guidance on which the effect on the DRT can be achieved in 86.4 % of cases.
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