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. 2022 Dec 16;101(1):47–59. doi: 10.1159/000526877

Artifacts Can Be Deceiving: The Actual Location of Deep Brain Stimulation Electrodes Differs from the Artifact Seen on Magnetic Resonance Images

Noa B Nuzov a,b, Bhumi Bhusal b, Kaylee R Henry a, Fuchang Jiang a, Jasmine Vu a,b, Joshua M Rosenow c, Julie G Pilitsis d, Behzad Elahi e, Laleh Golestanirad a,b,*
PMCID: PMC9932848  NIHMSID: NIHMS1835721  PMID: 36529124

Abstract

Introduction

Deep brain stimulation (DBS) is a common treatment for a variety of neurological and psychiatric disorders. Recent studies have highlighted the role of neuroimaging in localizing the position of electrode contacts relative to target brain areas in order to optimize DBS programming. Among different imaging methods, postoperative magnetic resonance imaging (MRI) has been widely used for DBS electrode localization; however, the geometrical distortion induced by the lead limits its accuracy. In this work, we investigated to what degree the difference between the actual location of the lead's tip and the location of the tip estimated from the MRI artifact varies depending on the MRI sequence parameters such as acquisition plane and phase encoding direction, as well as the lead's extracranial configuration. Accordingly, an imaging technique to increase the accuracy of lead localization was devised and discussed.

Methods

We designed and constructed an anthropomorphic phantom with an implanted DBS system following 18 clinically relevant configurations. The phantom was scanned at a Siemens 1.5 Tesla Aera scanner using a T<sub>1</sub>MPRAGE sequence optimized for clinical use and a T<sub>1</sub>TSE sequence optimized for research purposes. We varied slice acquisition plane and phase encoding direction and calculated the distance between the caudal tip of the DBS lead MRI artifact and the actual tip of the lead, as estimated from MRI reference markers.

Results

Imaging parameters and lead configuration substantially altered the difference in the depth of the lead within its MRI artifact on the scale of several millimeters − with a difference as large as 4.99 mm. The actual tip of the DBS lead was found to be consistently more rostral than the tip estimated from the MR image artifact. The smallest difference between the tip of the DBS lead and the tip of the MRI artifact using the clinically relevant sequence (i.e., T<sub>1</sub>MPRAGE) was found with the sagittal acquisition plane and anterior-posterior phase encoding direction.

Discussion/Conclusion

The actual tip of an implanted DBS lead is located up to several millimeters rostral to the tip of the lead's artifact on postoperative MR images. This distance depends on the MRI sequence parameters and the DBS system's extracranial trajectory. MRI parameters may be altered to improve this localization.

Keywords: Deep brain stimulation, Magnetic resonance imaging, Electrode localization, Magnetic resonance imaging artifact, Anthropomorphic phantom

Introduction

Deep brain stimulation (DBS) is a neurosurgical procedure that involves implanting electrodes into specific brain regions and delivering electrical pulses via an implantable pulse generator (IPG) to improve symptoms of a variety of chronic neurological disorders. DBS may be used to improve quality of life for people with movement disorders such as Parkinson's disease [1, 2], essential tremor [3, 4], and dystonia [5, 6]. Furthermore, DBS is FDA-approved for treatment of epilepsy [7, 8], severe obsessive-compulsive disorder [9, 10, 11], and is undergoing trials for treating major depression [12, 13] and Alzheimer's disease [14, 15]. In some cases, DBS can be used at one of several targets to treat a single disorder. For example, improvements in specific Parkinson's disease symptoms have been found when targeting either the subthalamic nucleus or the globus pallidus internus [16, 17].

Since the therapeutic effects of DBS heavily depend on the anatomical location of the implanted contacts within the target [18, 19], it is crucial to assess the accuracy of different imaging modalities in determining the actual coordinates of an implanted DBS electrode. Valid electrode localization allows for the correct correlation of clinical outcomes with electrode position, as well as better compensation of any positioning error with changes in stimulation programming [20, 21, 22, 23]. Magnetic resonance imaging (MRI) is commonly used for postoperative imaging of DBS electrodes thanks to studies addressing its safety [24, 25, 26, 27, 28, 29, 30]. However, because DBS leads contain metallic materials, significant susceptibility artifacts are apparent on MRI scans, hindering accurate electrode localization [31]. The artifact also has a radiofrequency (RF) component due to secondary magnetic fields induced on lead wires by MRI transmit fields, causing hypointense and hyperintense areas within the lead's general artifact. The artifact is much larger than the lead itself [32, 33], making it difficult to identify the precise locations of the contacts and the lead's tip. Additionally, since the lead is implanted at an angle deviated from the MRI scanner's main magnetic field, the artifact shape becomes more complex and has varying widths at different levels along the lead [34].

The most common method for DBS lead localization involves registering postoperative or intraoperative computed tomography (CT) images to preoperative MRI scans, using the caudal tip of the lead's hyperintense artifact on CT images to represent the actual tip of the lead [35]. However, DBS localization using CT/MRI fusion compared to postoperative MRI alone, where the tip of the lead is similarly chosen as the caudal tip of the MRI hypointense artifact, has been inconsistent. Some studies have found the difference in the lead's location between the two methods to be small enough to deem either method accurate, specifically ≤1 mm [36, 37, 38, 39], while others have concluded that the difference between the two is too large to ignore, as high as 2.75 mm [34, 40, 41]. Additionally, the registration of CT to MR images introduces a registration error, which can vary significantly depending on the type of software used [39, 42, 43]. Most importantly, CT/MRI fusion does not adequately account for brain shift [44, 45, 46] and pneumocephalus [47], which usually occur after lead implantation. One study also identified that lead migrations could occur due to technical error during implantation and poor fixation of the DBS lead to the skull [48]. Due to these errors and discrepancies, a method for accurately determining lead position through postoperative MR images alone is highly desired.

The goal of this study was to quantify the distance between the actual location of the tip of a DBS lead and the tip of the MRI artifact under varying imaging conditions and device configurations. We performed experiments with an anthropomorphic phantom implanted with a commercially available DBS system to precisely determine the ground truth and assess the MRI artifact for different lead trajectories and pulse sequence parameters. To facilitate the translation of our findings, we used a clinically optimized T1MPRAGE sequence at 1.5 Tesla (T) to compare the effect of pulse sequence parameters on determining the actual location of the DBS lead tip. Finally, we devised a technique to better localize the tip of the DBS lead relative to the tip of the MRI artifact and quantified its accuracy.

Materials and Methods

Phantom Design and Construction

Experiments were performed in a head-and-torso human-shaped phantom representing an adult (length 65 cm, width 45 cm, volume 26 L). The design and construction of the anthropomorphic phantom are described elsewhere [49]. We also designed 3D-printed grids, posts, and an IPG holder to help position the DBS system in a well-controlled and stable configuration similar to clinical cases. To determine the true position of the lead, a custom structure was designed and fabricated, which held the lead at its center along with four capillary glass tubes at equal distances from the lead (shown in Fig. 1a). The custom holder prevented bending of the lead post-implantation which is a common occurrence in patients. The glass tubes acted as MRI reference markers since their artifacts were minimally distorted, which was confirmed through statistical analysis. To assess the error due to variation of the markers' artifacts, we calculated the Euclidean distance between each pair of opposite markers for every sequence and trajectory. The standard deviation of the distances was 0.2 mm, which was deemed small enough to not affect lead localization.

Fig. 1.

Fig. 1

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a 3D model of the DBS lead, custom holder (gray), and markers (blue). b Side view of the holder with lead and markers. c Boston Scientific DB-2202-45 directional lead used in experiments. d Top view of the holder with lead and markers.

Attention was paid to assure that the lead and markers were held completely straight and parallel, with the tips of all tube markers manually lined up to the same height as the tip of the lead, namely, at 30 mm below the bottom of the holder (shown in Fig. 1b). The holder held each marker exactly 5 mm away from the lead in the plane perpendicular to the lead's shaft (shown in Fig. 1d). The lead and markers were attached to the inside of the phantom's skull on the right side with a depth and penetration angle similar to what occurs in human patients (shown in Fig. 2c). The electric conductivity of the medium surrounding the lead is shown to affect the field distortion and by proxy, the image artifact [26]. For this reason, we filled the skull with saline-doped agar solution with an electrical conductivity of σ = 0.34 Siemens per meter and relative permittivity of εr = 73.82, which is between the electrical properties of the brain gray and white matter. The rest of the phantom was filled with approximately 19 L of saline (2.6 g NaCl per liter of double-distilled water) with electrical conductivity σ = 0.52 Siemens per meter and relative permittivity εr = 80.12, similar to the electrical properties of average tissue.

Fig. 2.

Fig. 2

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a Phantom setup for a contralateral extracranial trajectory. b Phantom setup for an ipsilateral extracranial trajectory. c Lead and marker holder attached to the inside of the right side of the skull. The z-axis is marked as the axis along the lead's shaft. d Postoperative CT was used to segment trajectory 5 from patient (top) alongside the manually replicated trajectory used in the experiments (bottom). The right-sided trajectory was used (yellow box). e Phantom setup filled with saline entering the MRI scanner.

DBS System Configurations

Experiments were performed with a 45-cm 8-contact directional lead (Boston Scientific, DB-2202-45, Vercise CartesiaTM) (Marlborough, MA, USA) (shown in Fig. 1c). The lead was connected to a 55-cm extension (Boston Scientific, NM-3138-55) which interfaced with the IPG (Boston Scientific, DB-1200, Vercise GeviaTM). The IPG was positioned inside the holder which was then placed in the phantom's pectoral region similar to the most common configuration in patients (shown in Fig. 2a, b). A grid was placed inside the phantom to symmetrically alternate the IPG between the left and right sides of the patient for contralateral (shown in Fig. 2a) and ipsilateral (shown in Fig. 2b) trajectories, respectively. The extension was routed along the neck toward the IPG using posts.

The extracranial trajectory of DBS leads has been shown to affect their image artifact [49]. This is because lead trajectory affects the magnitude of RF-induced currents on internal wires [25, 50, 51, 52], which causes the RF artifact (as well as RF heating). For this reason, we examined 18 clinically relevant lead trajectories (shown in Fig. 3) from which the first three were trajectories that exhibited moderate, minimum, and maximum RF heating at 1.5 T, respectively, as determined by Bhusal et al. [49]. These included trajectories with (1) two concentric loops around the burr hole then routed toward the mastoid bone, (2) two concentric loops near the temporal bone then routed toward the mastoid bone, and (3) no loops on the skull routed toward the mastoid bone (shown in Fig. 3). The latter 15 trajectories were derived from images of patients operated at Northwestern Memorial Hospital (n = 7) and Albany Medical Center (n = 8) (shown in Fig. 2d). Trajectories 1 through 13 were contralateral, and trajectories 14 through 18 were ipsilateral relative to the side of the IPG. For all trajectories, the excess of the lead extension was looped around the anterior surface of the IPG. The DBS system was programmed to MRI mode for the entire duration of the experiment.

Fig. 3.

Fig. 3

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Photos of the extracranial trajectories 1–18 used in experiments.

MRI Sequences

The phantom was placed inside a 20-channel receive-only head/neck coil and scanned at a Siemens 1.5 T Aera scanner (shown in Fig. 2e) using T1MPRAGE and T1TSE sequences with parameters given in Table 1. The T1MPRAGE sequence parameters were similar to those applied in the postoperative DBS workup of patients at Northwestern Memorial Hospital. In order to assess the effects of slice selection and phase encoding direction on the lead's artifact, each sequence was repeated with axial (AX), sagittal (SAG), and coronal (COR) slice selection directions, as well as different corresponding phase encoding directions that did not cause aliasing (shown in Table 1). For the T1TSE sequences only, the AX scans were done perpendicular to the lead's shaft, while the SAG and COR scans were done parallel to the lead to illustrate unique patterning on the artifact.

Table 1.

Parameters for MRI sequences at 1.5 T

Sequence type
T1MPRAGE T1TSE
Voxel size, mm3 0.7 × 0.7 × 0.7 0.3 × 0.3 × 1.1
Field of view, mm 256 170
Slice thickness, mm 0.70 1.1
Echo time, ms 3.89 12
Repetition time, ms 2,000 2,240 (AX); 1,060 (SAG, COR)
Bandwidth, Hz 150 190
Base resolution 384 256
No. of averages 1 2
Acquisition planes AX, SAG, COR AX, SAG, COR
B1*rms, µT 0.58 3.00 (COR); 2.99 (SAG); 2.98 (AX)
Acquisition time, min 12:50 8:43 (AX); 4:08 (COR, SAG)
Phase encoding AX - A-P, R-L
directions SAG - A-P COR - R-L
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AX, axial; SAG, sagittal; COR, coronal; A-P, anterior-posterior; R-L, right-left.

Image Segmentation and Artifact Analysis

MRI DICOM images were processed in 3D Slicer [53] where the thresholding tool was used to mask out the areas of hypointense signal (shown in Fig. 4a). These masks were used to create 3D objects of the lead and marker artifacts which were then exported to a CAD tool, Rhino 3D [54], for further processing (shown in Fig. 4b). Within Rhino 3D, we created individual center lines for the lead and marker artifacts and extracted the most caudal point of the centerline through the lead's artifact to represent the “tip of the lead's artifact” (shown in Fig. 4c). To identify the ground truth, we first found the intersection of the two orthogonal planes that passed through the centers of each diagonal pair of markers and then selected the most caudal point of this line to represent the “actual tip of the lead” (shown in Fig. 4d). For marker and lead artifacts that were highly distorted (e.g., trajectory 3) such that a centerline could not be made, the tips were chosen manually at the most caudal vertex of the artifact mesh. A line was connected between the actual tip of the lead and the tip of the lead's artifact, D (shown in Fig. 4e).

Fig. 4.

Fig. 4

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a MR image for trajectory 1, T1MPRAGE sequence, axial acquisition plane, anterior-posterior phase encoding direction. b Segmented 3D mask of the artifacts thresholded from 3D Slicer. c Mask of the lead's artifact in Rhino (gray), centerline through the lead's artifact (blue), and caudal point represents the tip of the lead's MRI artifact (blue point). d Mask of the marker's artifacts (gray), the intersection of the black planes represents the actual center of the DBS lead (red line), and the caudal tip of the DBS lead (red point). e Line D (black) between the actual tip of the lead (red point) and the tip of the lead's MRI artifact (blue point). f Directional distance dz (green) from the actual lead tip to the tip of lead's MRI artifact parallel to z-axis. Dxy (magenta) is line D between actual lead tip and lead's artifact tip projected onto the plane perpendicular to lead's shaft or z-axis.

To quantify the distance between the actual tip of the lead and tip of the artifact, we chose a coordinate system where the z-axis was aligned with the actual centerline of the lead and pointed through the lead's shaft in the caudal direction (shown in Fig. 4d, e). The Euclidean distance between the tip of the lead's MRI artifact and the actual tip of the lead, D, was found (shown in Fig. 4f). The directional difference in z-coordinates between the tip of the lead's MRI artifact and the actual tip of the lead dz represented the depth of the MRI artifact in the caudal direction along the lead's shaft below the tip of the lead (shown in Fig. 4f). The perpendicular distance Dxy represents the magnitude of the projection of the line D onto the x-y plane perpendicular to the lead's shaft (shown in Fig. 4f). Microsoft Excel was used to calculate all distance formulas, averages, and standard deviations [55].

Statistical Analysis

Distributions of the directional distance dz were grouped by sequence parameters, where there were 8 total sequences as given in Table 1 each repeated with n = 18 trajectories. Due to normal underlying distributions but unequal variance, Welch's ANOVA was done to identify any significant differences in means between dz groups (α = 0.05). If any significance was detected for dz, the Games-Howell post hoc test was applied to identify the significantly different pairs (α = 0.05). Statistical tests were not done with the Euclidean distance D and the perpendicular distance Dxy as these measurements are not directional and cannot be used to approximate lead location. All statistical tests were performed using the software R [56] run in RStudio [57].

Results

Changing the sequence type, acquisition plane, phase encoding direction, and extracranial trajectory of the lead also substantially changed the directional, longitudinal distance dz between the actual tip of the lead and the tip of the lead's artifact (shown in Fig. 5). In all cases, the tip of the lead's artifact was more caudal along the axis of the lead's shaft than the actual tip of the lead. MRI scans of all trajectories across all sequences are shown in online supplementary Figures 1, through 4 (for all online suppl. material, see www.karger.com/doi/10.1159/000526877).

Fig. 5.

Fig. 5

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Directional distance dz for all trajectories and sequence parameters for T1MPRAGE and T1TSE in millimeters. Red lines represent the mean for each sequence. Trajectories 1–13 were contralateral and 14–18 ipsilateral. Trajectories 1–3 represent extreme SAR cases: (1) moderate heating, (2) least heating, (3) most heating.

Table 2 gives the mean ± standard deviation of dz (pooled over 18 trajectories). For the T1MPRAGE sequence, the largest average dz occurred for the AX acquisition plane and right-left (R-L) phase encoding direction, while the smallest average dz was for the SAG acquisition plane and anterior-posterior (A-P) phase encoding direction. For the T1TSE sequence, the largest mean dz occurred for the COR acquisition plane and R-L phase encoding direction, while the smallest mean dz for the AX acquisition plane and R-L phase encoding direction. For both T1MPRAGE and T1TSE sequences, the sensitivity to trajectory variation was minimized (i.e., the minimum standard deviation was observed in dz) when slice selection was in the COR direction and phase encoding was in the R-L direction.

Table 2.

Averaged directional distance dz (

graphic file with name sfn-0101-0047-gu01.jpg

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) ± standard deviation in mm across all trajectories for each sequence
Sequence type
T1MPRAGE T1TSE
AX, A-P 3.569±0.509 1.928±0.295
AX, R-L 3.802±0.547 0.810±0.383
SAG, A-P 2.216±0.362 0.966±0.510
COR, R-L 2.801±0.271 2.105±0.195
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AX, axial; SAG, sagittal; COR, coronal; A-P, anterior-posterior; R-L, right-left.

The mean value of dz for each respective sequence represents how far one must go rostrally along the lead's shaft to identify the actual depth of the DBS lead tip (shown in Table 2). The difference between the individual dz values and the means for each respective sequence (i.e., dz − mean dz) was also found to demonstrate the range of error that would occur when using only the mean as the estimate of actual lead depth (shown in Fig. 6).

Fig. 6.

Fig. 6

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Difference between directional distances dz and the mean dz (dz−) across all trajectories for each unique sequence in millimeters. Trajectories 1–13 were contralateral and 14–18 ipsilateral. Trajectories 1–3 represent extreme SAR cases: (1) moderate heating, (2) least heating, (3) most heating.

Welch's ANOVA indicated that there was at least one pairwise comparison of mean dz with statistical significance (p < 0.001). Post hoc analysis using G*Power calculated an effect size of 1.018 and power of 0.974 for the ANOVA [58]. The Games-Howell post hoc test found that 23 out of 28 possible pairwise comparisons were statistically significant (p < 0.05) (shown in Table 3). Sequences that had the same acquisition plane and phase encoding directions, but different sequence types (T1MPRAGE vs. T1TSE), had a difference in means that was statistically significant, which meant sequence type had an effect on the directional distance dz. For both T1MPRAGE and T1TSE, there were statistically significant differences between acquisition planes, even those with the same phase encoding direction. Lastly, for T1TSE, the AX acquisition plane scans were statistically different, demonstrating the significant effects of phase encoding direction (A-P vs. R-L).

Table 3.

Results of Games-Howell post hoc pairwise comparisons for mean dz (

graphic file with name sfn-0101-0047-gu02.jpg

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) (*** p < 0.001; **** p < 0.0001; ns, not significant)
T1MPRAGE
 T1TSE
AX, A-P AX, R-L SAG, A-P COR, R-L AX, A-P AX, R-L SAG, A-P COR, R-L
T1MPRAGE AX, A-P ns **** *** **** **** **** ****
AX, R-L ns **** **** **** **** **** ****
SAG, A-P **** **** *** ns **** **** ns
COR, R-L *** **** *** **** **** **** ****
T1TSE AX, A-P **** **** ns **** **** **** ns
AX, R-L **** **** **** **** **** ns ****
SAG, A-P **** **** **** **** **** ns ****
COR, R-L **** **** ns **** ns **** ****
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AX, axial; SAG, sagittal; COR, coronal; A-P, anterior-posterior; R-L, right-left.

The value D represents the Euclidean distance, or length of the line, between the actual lead tip and the tip of the lead's MRI artifact (shown in Fig. 7). All values of D were greater than zero, indicating a deviation of the artifact's tip from the actual lead tip in 3D space.

Fig. 7.

Fig. 7

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Length of the line D between the tip of the DBS lead and the tip of the lead's MRI artifact across all trajectories and sequence parameters for T1MPRAGE and T1TSE in millimeters. Red lines represent the mean for each sequence.

The values Dxy representing the magnitude of the projection of line D between the actual lead tip and the artifact's tip onto the x-y plane perpendicular to the lead's shaft were also found (shown in Fig. 8). The Dxy values were all greater than zero, indicating deviation of the artifact's tip perpendicular to the z-axis or the actual lead's shaft.

Fig. 8.

Fig. 8

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Magnitude of the perpendicular line Dxy across all trajectories and sequence parameters for T1MPRAGE and T1TSE in millimeters. Red lines represent the mean for each sequence.

Discussion/Conclusion

Current methods of determining the position of DBS electrodes from postoperative MR images rely on the assumption that the tip of the lead is located at the most caudal tip of the artifact [36, 37, 40]. However, researchers have recently begun formally disproving this assumption through phantom experiments [59]. To our knowledge, this is the first study identifying the difference in actual DBS lead positioning relative to its MRI artifact using a directional DBS lead system scanned at clinically relevant 1.5 T across multiple extracranial trajectories and varied MRI sequence parameters. We found that the actual tip of the lead is never located at the caudal tip of the MR image artifact, and the degree of variation along the lead's shaft axis (i.e., rostral-caudal) changes with MRI sequence type, acquisition plane, phase encoding direction, and the extracranial trajectory of the DBS system.

One of the earliest papers investigating the MRI artifact of DBS leads found that the hypointense artifact extended 1.4 mm below the first contact of the Medtronic ActivaTM 3389 lead (Medtronic, Minneapolis, MN) [33], while the lead itself has a 1.5-mm-long plastic tip under the first contact which induces its own void artifact [42]. Furthermore, the same DBS lead was investigated in terms of its postoperative CT artifact, which only extended 1.2 mm below the bottom of the first contact [60]. This difference in the length of the postoperative CT and MRI artifacts demonstrates that selecting the tip of the artifact is not an appropriate method of localizing the lead across both modalities and also likely explains disparities in the CT/MRI fusion versus postoperative MRI localization research.

A study of patients who had their DBS leads removed suggested that the center of the hypointense MRI artifact can be assumed to justly represent the lead's centerline in DBS patients [61]. This would allow for the determination of the mediolateral and anteroposterior coordinates of the lead, but the exact location of the lead's tip in the rostral-caudal direction, z, was not determined [62]. A more recent phantom study investigated the distance between the tip of the actual lead and the tip of the lead's MRI artifact and found differences using T1-weighted three-dimensional turbo-field echo and T2-weighted turbo spin echo sequences at 3 T with varying implantation angles; however, scans at this strength are not clinically used [59]. This study also disproved the previous determination [61] that the centerline of the lead's shaft is aligned with the center of the lead's MRI artifact. Furthermore, our nonzero values for the magnitude of deviation of the artifact's tip in the plane perpendicular to the lead's shaft, Dxy, support this newer conclusion.

Previous postoperative MRI studies have only been done using lead models with 4 ring-shaped omnidirectional contacts [33, 34, 40, 41, 59], while the investigation using directional or segmented electrodes is absent. So, our study employed an anthropomorphic phantom implanted with a directional DBS lead system where the effects of the extracranial trajectory, both contralateral and ipsilateral to the IPG, were investigated for the first time on the MRI lead's artifact. With the ground truth known, we determined the distance dz parallel to the lead's shaft between the actual tip of the DBS lead and the tip of the lead's MRI artifact. The actual tip of the lead is always located in an anatomical position that is less deep or more rostral to the tip of the artifact. At a minimum, this distance dz along the lead's shaft axis was 0.25 mm but varied up to 4.99 mm under certain conditions.

In this experiment, the T1MPRAGE sequence was based on routine scanning protocols of our DBS patients at Northwestern Memorial Hospital, where the AX acquisition plane and R-L phase encoding direction are used. The T1TSE sequence is valuable for contact localization since it demonstrates a unique alternating bright and dark intensity pattern representing the contacts and plastic insulation near the proximal end of the DBS lead (shown in Fig. 9c). The unique patterning has been demonstrated on other types of sequences, such as T2TSE, and new sequences have also been recently explored that are optimal for DBS lead localization [63].

Fig. 9.

Fig. 9

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a T1MPRAGE, axial acquisition plane, anterior-posterior phase encoding direction, scan of trajectory 1. b T1MPRAGE, axial acquisition plane, anterior-posterior phase encoding direction, scan of trajectory 3. c T1TSE, sagittal acquisition plane, anterior-posterior phase encoding direction, scan of trajectory 1. d T1TSE, sagittal acquisition plane, anterior-posterior phase encoding direction, scan of trajectory 3.

We found that mean dz was the smallest using the SAG acquisition plane and A-P phase encoding direction for T1MPRAGE, compared to the AX acquisition plane and R-L phase encoding direction for T1TSE. We also found that the artifacts and distances were affected by the extracranial trajectory of the lead (shown in Fig. 9). This was expected, as previous studies have shown that the extracranial trajectory of DBS systems affects their coupling with MRI electric fields [24, 49, 50, 52, 64, 65, 66], which in turn affects the RF-induced image artifact [49].

The overall largest distance dz between the actual lead tip and the artifact's tip was 4.99 mm for trajectory 6 (T1MPRAGE, AX acquisition plane, R-L phase encoding direction). This distance is quite large compared to small target brain structures such as the subthalamic nucleus, which can be around 6 × 4 × 5 mm3 in volume on MR images [67].

Our results challenge the paradigm in DBS lead localization that identifies the electrode tip as the center of the most caudal point within the MRI signal void, in agreement with more recent studies [33, 59]. Our value of dz represents the difference between the actual tip of the lead and the caudal tip of the lead's MRI artifact along the axis of the lead's shaft. We show that this distance varies depending on the MRI sequence parameters and the patient's extracranial trajectory. Acquisition plane and phase encoding direction had statistically significant differences in dz, demonstrating the importance of consistently reporting these parameters so mitigation techniques can be tailored accordingly. Therefore, for a better estimate of the depth of the DBS lead within its MRI artifact, one can reference Table 2 for the distance they should rostrally move along the lead's shaft to identify the actual lead tip. All in all, these results will have a significant impact on the clinical interpretation of the DBS outcome and in predictions of imaging-based computational models of stimulation [20, 68].

The results of this study are limited to the Siemens Aera 1.5 T scanner, the specific sequence parameters used, and unilateral DBS lead implantations on a patient's right side. Overall, more work is required to investigate the differences in the offset of the lead's artifact tip from the actual lead tip, including phantom experiments with the DBS lead implanted on the patient's left side and bilaterally. Other variables that should be investigated include DBS lead manufacturer, new MRI sequences, and variation among DBS lead models, which have different contact spacing and can be directional or nondirectional. Specifically, as the lead's material and geometry of interconnecting wires can affect both the susceptibility and nonsusceptibility artifacts [69, 70], different lead models should be studied separately.

Statement of Ethics

No ethics statement is required for this study. No human or animal subjects or materials were used.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This research study was supported by the National Institutes of Health grants R01EB030324 and T32EB025766.

Author Contributions

Noa Nuzov: conceptualization, methodology, software, formal analysis, investigation, and writing − original draft, review, and editing. Bhumi Bhusal: investigation, methodology, and writing − review and editing. Kaylee Henry: software and writing − review and editing. Fuchang Jiang: conceptualization and writing − review and editing. Jasmine Vu and Joshua Rosenow: resources and writing − review and editing. Julie Pilitsis: resources. Behzad Elahi: funding acquisition and writing − review and editing. Laleh Golestani Rad: conceptualization, methodology, resources, writing − review and editing, supervision, and funding acquisition.

Data Availability Statement

Data may be requested from the corresponding author due to its large size. 3D Slicer is an open-source software available online for download. A 90-day free trial of Rhinoceros 3D is also available.

Supplementary Material

Supplementary data

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Supplementary data

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Supplementary data

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Supplementary data

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Acknowledgment

Noa Nuzov thanks Dr. Richard Niemzcura at Northwestern Memorial Hospital for access to patient DBS MRI protocols and clinical observation.

Funding Statement

This research study was supported by the National Institutes of Health grants R01EB030324 and T32EB025766.

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Data Availability Statement

Data may be requested from the corresponding author due to its large size. 3D Slicer is an open-source software available online for download. A 90-day free trial of Rhinoceros 3D is also available.

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