Delineation of the Centromedian Nucleus for Epilepsy Neuromodulation Using Deep Learning Reconstruction of White Matter–Nulled Imaging

BACKGROUND AND PURPOSE: Neuromodulation of the centromedian nucleus (CM) of the thalamus has shown promise in treating refractory epilepsy, particularly for idiopathic generalized epilepsy and Lennox-Gastaut syndrome. However, precise targeting of CM remains challenging. The combination of deep learning reconstruction (DLR) and fast gray matter acquisition T1 inversion recovery (FGATIR) offers potential improvements in visualization of CM for deep brain stimulation (DBS) targeting. The goal of the study was to evaluate the visualization of the putative CM on DLR-FGATIR and its alignment with atlas-defined CM boundaries, with the aim of facilitating direct targeting of CM for neuromodulation.

MATERIALS AND METHODS: This retrospective study included 12 patients with drug-resistant epilepsy treated with thalamic neuromodulation by using DLR-FGATIR for direct targeting. Postcontrast-T1-weighted MRI, DLR-FGATIR, and postoperative CT were coregistered and normalized into Montreal Neurological Institute (MNI) space and compared with the Morel histologic atlas. Contrast-to-noise ratios were measured between CM and neighboring nuclei. CM segmentations were compared between an experienced rater, a trainee rater, the Morel atlas, and the Thalamus Optimized Multi Atlas Segmentation (THOMAS) atlas (derived from expert segmentation of high-field MRI) by using the Sorenson-Dice coefficient (Dice score, a measure of overlap) and volume ratios. The number of electrode contacts within the Morel atlas CM was assessed.

RESULTS: On DLR-FGATIR, CM was visible as an ovoid hypointensity in the intralaminar thalamus. Contrast-to-noise ratios were highest (P < .001) for the mediodorsal and medial pulvinar nuclei. Dice score with the Morel atlas CM was higher (median 0.49, interquartile range 0.40–0.58) for the experienced rater (P < .001) than the trainee rater (0.32, 0.19–0.46) and no different (P = .32) than the THOMAS atlas CM (0.56, 0.55–0.58). Both raters and the THOMAS atlas tended to under-segment the lateral portion of the Morel atlas CM, reflected by smaller segmentation volumes (P < .001). All electrodes targeting CM based on DLR-FGATIR traversed the Morel atlas CM.

CONCLUSIONS: DLR-FGATIR permitted visualization and delineation of CM commensurate with a group atlas derived from high-field MRI. This technique provided reliable guidance for accurate electrode placement within CM, highlighting its potential use for direct targeting.