Tractography Study of Deep Brain Stimulation of the Anterior Cingulate Cortex in Chronic Pain: Key to Improve the Targeting

• Published in: World neurosurgery Vol. 86; pp. 361 - 370.e3
• Main Authors: Boccard, Sandra G.J, Fernandes, Henrique M, Jbabdi, Saad, Van Hartevelt, Tim J, Kringelbach, Morten L, Quaghebeur, Gerardine, Moir, Liz, Mancebo, Victor Piqueras, Pereira, Erlick A.C, Fitzgerald, James J, Green, Alexander L, Stein, John, Aziz, Tipu Z
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-02-2016
• Subjects: Anterior cingulate cortex; Chronic Pain - surgery; Deep brain stimulation; Deep Brain Stimulation - methods; Diffusion Tensor Imaging - methods; Electrodes; Female; Gyrus Cinguli - anatomy & histology; Gyrus Cinguli - surgery; Humans; Image Processing, Computer-Assisted; Male; Medial Forebrain Bundle - anatomy & histology; Medial Forebrain Bundle - surgery; Middle Aged; Neurosurgery; Neurosurgical Procedures - methods; Pain Measurement; Precuneus; Targeting; Thalamus - anatomy & histology; Thalamus - surgery; Tractography; Treatment Outcome; PVG; EQ-5D; Anterior thalamic radiation; Deep brain stimulation; Visual Analog Scale; VAT; VAS; STN; Ventromedial prefrontal cortex; MPQ; Posterior cingulate cortex; Brachial plexus injury; Computed tomography; DBS; Subthalamic nucleus; UO; FSL; Superior middle frontal gyrus; Medial forebrain bundle; FMRIB Software Library; ROI; SMF; Diffusion tensor imaging; SF-36; Unsuccessful outcomes; PCC; Volume of activated tissue; DTI; BPI; FLIRT; FBSS; Targeting; Diffusion magnetic resonance imaging; MRI; vmPFC; MFB; MNI; dMRI; FMRIB linear image registration tools; Region of interest; Precuneus; Successful outcomes; SO; McGill Pain Questionnaire; ACC; Failed back surgery syndrome; Anterior cingulate cortex; Tractography; Periaqueductal gray area; Brain extraction tool; Short-Form36 questionnaire; Periventricular gray area; BET; CT; Montreal Neurological Institute; Magnetic resonance imaging; PAG; ATR; EuroQol questionnaire
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2015.08.065

Background Deep brain stimulation (DBS) of the anterior cingulate cortex (ACC) is a new treatment for alleviating intractable neuropathic pain. However, it fails to help some patients. The large size of the ACC and the intersubject variability make it difficult to determine the optimal site to position DBS electrodes. The aim of this work was therefore to compare the ACC connectivity of patients with successful versus unsuccessful DBS outcomes to help guide future electrode placement. Methods Diffusion magnetic resonance imaging (dMRI) and probabilistic tractography were performed preoperatively in 8 chronic pain patients (age 53.4 ± 6.1 years, 2 females) with ACC DBS, of whom 6 had successful (SO) and 2 unsuccessful outcomes (UOs) during a period of trialing. Results The number of patients was too small to demonstrate any statistically significant differences. Nevertheless, we observed differences between patients with successful and unsuccessful outcomes in the fiber tract projections emanating from the volume of activated tissue around the electrodes. A strong connectivity to the precuneus area seems to predict unsuccessful outcomes in our patients (UO: 160n/SO: 27n), with ( n ), the number of streamlines per nonzero voxel. On the other hand, connectivity to the thalamus and brainstem through the medial forebrain bundle (MFB) was only observed in SO patients. Conclusions These findings could help improve presurgical planning by optimizing electrode placement, to selectively target the tracts that help to relieve patients' pain and to avoid those leading to unwanted effects.