Implementation of Intraoperative Computed Tomography for Deep Brain Stimulation: Pitfalls and Optimization of Workflow, Accuracy, and Radiation Exposure

OBJECTIVE: Deep brain stimulation (DBS) is an effective treatment for movement disorders. Stereotactic electrode placement can be guided by intraoperative imaging, which also allows for immediate intraoperative quality control. This article is about implementation and refining a workflow applying intraoperative computed tomography (iCT) for DBS. METHODS: Eighteen patients underwent DBS with bilateral implantation of directional electrodes applying a 32-slice movable computed tomography scanner in combination with microelectrode recording. RESULTS: iCT led to a significant decrease in overall procedural time, despite performing multiple scans. In 3 of the initial 5 cases, iCT caused an adjustment of the final electrodes demonstrating the learning curve and the necessity to integrate road mapping for the exchange of microelectrode to final electrode. Implementation of low-dose computed tomography protocols added microelectrode iCT to the refined workflow, resulting in an intraoperative adjustment of a trajectory in 1 patient. Low-dose protocols lowered the total effective dose to 1.15 mSv, that is, a reduction by a factor of 3.5 compared to a standard non-iCT DBS procedure, despite repeated iCTs. Intraoperative lead detection based on final iCT revealed a radial error of 1.04 +/- 0.58 mm and a vector error of 2.28 +/- 0.97 mm compared to the preoperative planning, adjusted by the findings of microelectrode recording. CONCLUSIONS: iCT can be easily integrated into the surgical workflow resulting in an overall efficient timesaving procedure. Repeated intraoperative scanning ensures reliable electrode placement, although low-dose scanning protocols prevent extensive radiation exposure. iCT of microelectrodes is feasible and led to the adjustment of 1 electrode.