When medically intractable epilepsy is multifocal or focal but poorly localized, neuromodulation can be useful therapy. One such technique is deep brain stimulation (DBS) targeting the anterior nucleus of the thalamus (ANT). Unfortunately, the ANT is difficult to visualize in standard MRI sequences and its indirect targeting is difficult because of thalamic variability and atrophy in patients with epilepsy. The following study describes the novel use of the fast gray matter acquisition T1 inversion recovery (FGATIR) MRI sequence to delineate the mammillothalamic tract for direct targeting of the ANT through visualizing the termination of the mammillothalamic tract in the ANT. The day prior to surgery in a 19-year-old, right-handed woman with a 5-year history of epilepsy, MRI was performed on a 3-T Siemens Prisma scanner (Siemens AG, Healthcare Sector) using a 64-channel head and neck coil. As part of the imaging protocol, noncontrast magnetization-prepared rapid gradient echo (MP-RAGE) and diffusion tensor imaging (DTI) sequences were obtained for targeting purposes. The ANT was directly targeted using the FGATIR sequence, and bilateral Medtronic 3389 leads were placed. At the last follow-up (2 months), the patient reported an approximate 75% decrease in seizure frequency, as well as a decrease in seizure severity.
Keywords: ANT = anterior nucleus of the thalamus; CMT = centromedian nucleus of the thalamus; CMTpf = CMT/parafascicular complex; DBS; DBS = deep brain stimulation; DISTAL = DBS Intrinsic Template Atlas; DTI = diffusion tensor imaging; EEG = electroencephalography; EPI = echo planar imaging; FGATIR; FGATIR = fast gray matter acquisition T1 inversion recovery; GRAPPA = generalized autocalibrating partial parallel acquisition; MNI = Montreal Neurological Institute; MP-RAGE = magnetization-prepared rapid gradient echo; SNR = signal-to-noise ratio; STIR = short-tau inversion recovery; VTA = volume of tissue activated; anterior nucleus; epilepsy.