Zusammenfassung
Voraussetzung für die therapeutische Anwendung der tiefen Hirnstimulation (THS) ist eine stereotaktisch-neurochirurgische Operation mit Implantation von Hirnelektroden in subkortikale Zielstrukturen des Gehirns und Verbindung dieser Elektroden mit einem subkutan implantierten Impulsgeber. Während der vergangenen 10–15 Jahre wurden dafür bestimmte Minimalanforderungen an technische Ausstattung und prozedurale Vorgehensweisen formuliert, die teilweise über systematische Untersuchungen auch quantitativ abgesichert sind. Nur durch richtiges Patientenmanagement, einen hohen technischen Aufwand sowie eine geeignete Operationstechnik können Komplikationen, die als unmittelbare Folge des durchgeführten Eingriffs zu sehen sind, auf ein Minimum reduziert werden. Hochauflösende Bildgebung ist die Basis für Zielpunktbestimmung, Zugangsplanung und Lagekontrolle der implantierten Hirnelektroden bzw. dient postoperativ dem Ausschluss einer iatrogenen intrazerebralen Blutung. Die Qualität der Operationsplanung hängt zusätzlich in hohem Maß von den Möglichkeiten der Bildbearbeitung und -betrachtung ab, die eine spezifisch dafür entwickelte Planungssoftware zulässt. Weitere Bereiche, für die Standards definiert wurden, betreffen die intraoperativ durchzuführenden elektrophysiologischen und klinischen Untersuchungen sowie allgemeine chirurgische Maßnahmen, die bei der Implantation der THS-Stimulationssysteme zu beachten sind. Diese Übersichtsarbeit beschreibt und bewertet unter Berücksichtigung der Fachliteratur die Anforderungen, die an die genannten Systemkomponenten und Arbeitsschritte zu stellen sind.
Summary
Surgery combining stereotactically guided implantation of brain electrodes in subcortical key structures of the brain with the connection of these brain electrodes to subcutaneously implanted impulse generators is one precondition for the therapeutic application of deep brain stimulation (DBS). During the last 10–15 years minimal requirements concerning this surgery have been formulated, addressing in particular technical equipment and operational procedures and being also in parts supported quantitatively by systematic investigations. Only appropriate patient management, high technical standards and an adequate surgical technique can minimize the frequency of those complications, which are supposed to be directly caused by surgery. High-resolution imaging is the basis for target definition, determination of the surgical approach, documentation of final electrode position and postoperative exclusion of iatrogenic intracerebral haemorrhage. In addition, the quality of treatment planning depends largely on the image processing and viewing possibilities provided by specific planning software. Further issues, for which standards are defined, address electrophysiological and clinical examinations to be performed intraoperatively and general surgical measures, which should be considered during implantation of DBS systems. This review summarizes and evaluates requirements imposed on the aforementioned system components and working steps, taking into consideration data from the literature.
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Der korrespondierende Autor weist auf folgende Beziehungen hin: Referententätigkeit für die Fa. Medtronic, Minneapolis, USA.
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Voges, J., Kiening, K., Krauss, J. et al. Neurochirurgische Standards bei tiefer Hirnstimulation. Nervenarzt 80, 666–672 (2009). https://doi.org/10.1007/s00115-009-2698-0
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DOI: https://doi.org/10.1007/s00115-009-2698-0