Neuronavigation using susceptibility-weighted venography: application to deep brain stimulation and comparison with gadolinium contrast

Careful trajectory planning on preoperative vascular imaging is an essential step in deep brain stimulation (DBS) to minimize risks of hemorrhagic complications and postoperative neurological deficits. This paper compares 2 MRI methods for visualizing cerebral vasculature and planning DBS probe trajectories: a single data set Ti-weighted scan with double-dose gadolinium contrast (Tlw-Gd) and a multi data set protocol consisting of a Ti-weighted structural, susceptibility-weighted venography, and time-of-flight angiography (T1w-SWI-TOF). Two neurosurgeons who specialize in neuromodulation surgery planned bilateral STN DBS in 18 patients with Parkinson's disease (36 hemispheres) using each protocol separately. Planned trajectories were then evaluated across all vascular data sets (Tlw-Gd, SWI, and TOF) to detect possible intersection with blood vessels along the entire path via an objective vesselness measure. The authors' results show that trajectories planned on Tlw-SWI-TOF successfully avoided the cerebral vasculature imaged by conventional T1w-Gd and did not suffer from missing vascular information or imprecise data set registration. Furthermore, with appropriate planning and visualization software, trajectory corridors planned on Tlw-SWI-TOF intersected significantly less fine vasculature that was not detected on the Tlw-Gd (p < 0.01 within 2 mm and p < 0.001 within 4 mm of the track centerline). The proposed Tlw-SWI-TOF protocol comes with minimal effects on the imaging and surgical workflow, improves vessel avoidance, and provides a safe costeffective alternative to injection of gadolinium contrast.