neurosurgeryНейрохирургияRussian journal of neurosurgery1683-32952587-7569Издательский дом "МедИНК"10.17650/1683-3295-2024-26-1-54-64neurosurgery-1496Research ArticleОРИГИНАЛЬНАЯ РАБОТАORIGINAL REPORTИндивидуальная вариабельность дентаторуброталамического тракта при планировании стереотаксических вмешательств у пациентов с треморомThe individual variability of the dentato-rubro-thalamic tract in the planning of stereotactic operations in patients with tremorhttps://orcid.org/0000-0003-1934-5458ХолявинА. И.KholyavinA. I.

Андрей Иванович Холявин

197376, Санкт-Петербург, ул. Академика Павлова, 9

Andrey Ivanovich Kholyavin 

9 Akademika Pavlova St., St. Petersburg 197376

Kholyavin@mail.ruhttps://orcid.org/0000-0002-2918-2771ПесковВ. А.PeskovA. V.

197376, Санкт-Петербург, ул. Академика Павлова, 9

9 Akademika Pavlova St., St. Petersburg 197376

https://orcid.org/0000-0002-1049-7765БергерА. О.BergerA. O. 

197376, Санкт-Петербург, ул. Академика Павлова, 9

9 Akademika Pavlova St., St. Petersburg 197376

ФГБУН «Институт мозга человека им. Н. П. Бехтеревой» Российской академии наукРоссияN. P. Bekhtereva Institute of Human Brain, Russian Academy of SciencesRussian Federation2024040420242615464Copyright © Холявин А.И., Песков В.А., Бергер А.О., 20242024Холявин А.И., Песков В.А., Бергер А.О.Kholyavin A.I., Peskov A.V., Berger A.O.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.therjn.com/jour/article/view/1496Введение

Введение. Стереотаксические операции на вентрально‑промежуточном ядре таламуса (Vim) и задней субталамической области (PSA) используют для хирургического лечения тремора. Поскольку эти структуры неразличимы в стандартных режимах магнитно‑резонансной томографии (МРТ), при операциях в основном применяют непрямое стереотаксическое наведение. МРТ‑трактография позволяет учитывать индивидуальную вариабельность структурмишеней при треморе, визуализируя мишень напрямую, однако в рутинную практику подготовки операций эта методика еще не вошла.

Цель исследования – изучение вариабельности положения дентаторуброталамического тракта (DRT), определенного по данным трактографии, по отношению к основным ориентирам для непрямого стереотаксического наведения, а также к структурам, видимым при МРТ в режиме FGATIR, для оценки обоснованности используемых в настоящее время методик подготовки операций при треморе.

Материалы и методы

Материалы и методы. Вероятностная МРТ‑трактография DRT по протоколу HARDY проведена 34 пациентам. Дополнительно получали томограммы в режимах 3D T1 аксиальными срезами с изотропным размером воксела, равным 1 мм, а также FLAIR сагиттальными срезами толщиной 1,12 мм с шагом 0,56 мм. Помимо этого, 11 пациентам выполняли серию срезов по программе FGATIR толщиной 1 мм без межсрезового промежутка.

Результаты

Результаты. Установлена существенная вариабельность положения DRT как в системе координат передней и задней комиссур, так и по отношению к стандартным мишеням для непрямого стереотаксического наведения. Кроме того, выявлена заметная межполушарная асимметрия положения трактов. Наименьшая степень отклонения от трактов отмечена для траекторий электродов для глубокой стимуляции мозга, имплантируемых в каудальную неопределенную зону (cZI) на уровне максимального диаметра красных ядер. Также установлена высокая степень соответствия между трактом и целевой зоной прелемнисковой радиации (Raprl) на томограммах в режиме FGATIR.

Выводы

Выводы. Стандартные целевые точки для непрямого наведения на мишени Vim и церебеллоталамический тракт в PSA дают отклонение >2 мм от DRT почти у половины пациентов. В то же время при наведении на стандартную целевую точку cZI в зоне воздействия на уровне 2‑го или 3‑го контакта электрода DRT находится в 76,5 % случаев. Режим FGATIR позволяет визуализировать структуру Raprl, при стереотаксическом наведении на которую воздействие на DRT может быть достигнуто в 86,4 % случаев.

Background

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

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

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

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

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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The authors declare that there are no conflicts of interest present.