Imaging of subthalamic nucleus and ventralis intermedius of the thalamus

The techniques of targeting the subthalamic nucleus (STN) and the ventralis intermedius nucleus (Vim) are similar, only the coordinates are different. Targeting ideally consists of gathering all data about a target and positioning the electrode correctly within that target. The electrode should be positioned within a statistical range of coordinates, where the neuronal firing fits a given pattern and responds to external stimuli, particularly to proprioceptive inputs, in a somatotopically organized manner. Moreover, final placement should provide the best clinical improvement of symptoms under the stimulation parameters expected to be used in the long term. This latter criterion is by far the most important, because intraoperative findings indicate the functional benefit for the patient, which is the ultimate purpose of this surgery. A variety of radiological modalities are available to provide data for electrode placement, but each type has its drawbacks. Ventriculography, although safe when performed accordingly to strict technical procedure, is the most precise method but provides more indirect targeting and is more invasive than magnetic resonance imaging (MRI). MRI is the best method for visualizing the STN and, to some extent, for discerning the Vim, but it is plagued with unpredictable and nonreproducible deformations that induce a systematic distortion. These shortcomings no doubt will be corrected in the near future, and the technologies will better assist us in the proper placement of electrodes, which will provide the patient with the highest possible benefit.