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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Deep brain stimulation &#40;DBS&#41; is an established treatment for advanced&#44; drug-refractory Parkinson&#39;s disease &#40;PD&#41;&#44; comprising the application of chronic high-frequency electrical stimulation through an electrode implanted in a specific brain target&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;2</span></a> It produces a superior improvement in quality of life and reduction of motor symptoms&#8217; severity than isolated pharmacological therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">3&#44;4</span></a> A commonly chosen target in PD is the subthalamic nucleus &#40;STN&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The therapeutic success of DBS depends on the accuracy of STN targeting&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#8211;7</span></a> Literature shows that it is essential to target the dorsolateral&#44; motor subdivision of the STN&#44; avoiding penetration of its limbic and associative subdivisions &#40;which might lead to executive function deficits and mood impairment&#41;&#44; or the laterally located internal capsule &#40;which could cause tonic muscular contractions and slurred speech&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;8</span></a> Thus&#44; accurate STN targeting requires rigorous care at different steps&#44; including planning and surgical execution&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; stereotactic neurosurgery relies on the assumption that brain structures are static while events such as brain shift can hinder the correct placement of the electrodes&#44; causing a discrepancy between the images acquired preoperatively and the actual location of structures during and after surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;9</span></a> This movement of the brain is due to various factors&#44; particularly the force of gravity&#44; and the invasion of the intracranial space by air and the loss of cerebrospinal fluid that occur during the opening of the dura mater&#44; causing an anterior pneumocephalus&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#8211;12</span></a> This explains why the shift generally occurs in a posterior direction when the patient is placed in a supine position during surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#44;14</span></a> While some studies argue that shift of subcortical structures is very limited and does not significantly affect clinical outcome&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#44;15</span></a> Hunsche et al&#46; defend that in bilateral DBS the brain shift that occurs after placing the first electrode should be considered relevant as it can affect the placement of the second one&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a> Other studies have also shown that more adjustment with MER and intraoperative macrostimulation is usually required for the correct placement of the second electrode&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;17</span></a> It is therefore possible to have a more significant shift &#40;thus increasing the distance between the planned target and the final electrode location&#41; on the second implanted side&#44; when compared to the first&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> The reduced accuracy in placement of the second electrode is related to a reduction in the threshold for adverse effects&#44; and a less pronounced improvement in symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Taking this into account&#44; this study aims to evaluate potential differences in targeting accuracy &#40;defined as final electrode position equal to initially planned target&#41;&#44; comparing the first and second implanted sides in patients undergoing bilateral STN-DBS surgery for PD&#46; We hypothesize that if there are no differences in targeting accuracy between the first and second sides&#44; then the frequency of choosing the central channel for final implantation will be similar for both&#46; However&#44; in case there are in fact differences&#44; then this should translate into a distinct quality of intraoperative electrophysiological recordings&#44; with an expected higher quality of STN signal detected in the central channel of the side with the better targeting accuracy &#40;in this case&#44; the first side&#41;&#46; In this situation&#44; another expected observation is a different magnitude of mismatch between the initially planned versus final electrode positions&#44; with a greater deviation on the second side&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0025" class="elsevierStylePara elsevierViewall">This observational retrospective cohort study included all consecutive patients who underwent simultaneous bilateral DBS surgery for the treatment of PD&#44; with the STN as the target&#44; from January 2019 to February 2021&#44; and who had at least one month of follow-up&#46; Patients who did not have a CT scan taken at least a month after the surgery&#44; or who lacked data about the initial stereotactic planning&#44; were excluded from this analysis&#46; Patient data was collected from medical records in our database&#46; The research protocol was approved by the ethics committee of the S&#227;o Jo&#227;o Hospital Centre&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical procedure</span><p id="par0030" class="elsevierStylePara elsevierViewall">Stereotactic planning was done by fusing a preoperative 1&#46;5<span class="elsevierStyleHsp" style=""></span>T or 3<span class="elsevierStyleHsp" style=""></span>T MRI with a stereotactic CT scan obtained on the morning of the surgery&#44; using FrameLink StealthStation 8&#174; &#40;Medtronic&#44; USA&#41;&#44; as previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a> After verification of fusion accuracy&#44; the mid AC-PC point was used to locate the anatomically defined target &#40;12<span class="elsevierStyleHsp" style=""></span>mm lateral&#44; 2<span class="elsevierStyleHsp" style=""></span>mm posterior and 4<span class="elsevierStyleHsp" style=""></span>mm inferior&#41;&#46; The final position of the target was confirmed through direct visualization of the STN in T2-weighted or T2 SPACE images&#44; followed by manual adjustment&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The surgery was performed with the patient supine&#44; with a 30&#176; head flexion&#44; and under local anaesthesia&#46; The first side operated was always contralateral to the most symptomatic side&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Whenever possible&#44; three steel cannulas and microelectrodes &#40;central&#44; anterior and lateral&#41; were inserted to perform stimulation&#46; MER was started 5<span class="elsevierStyleHsp" style=""></span>mm above the planned target&#44; advanced in 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm steps&#44; and extended 3&#8211;5<span class="elsevierStyleHsp" style=""></span>mm below the target point or until the substantia nigra was detected&#44; as previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a> Two experienced neurologists performed a visual and sound analysis of the single unit recordings captured by the high impedance electrodes&#44; and qualitatively scored each 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm step using the following scale&#58; 0 &#40;no signal&#41;&#44; 1 &#40;low-quality&#58; only traces visible&#41;&#44; 2 &#40;medium-quality&#58; sparse activity&#41; or 3 &#40;high-quality&#58; abundant STN-typical spikes&#41;&#46; The STN is characterized by a mean firing rate of 37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>Hz&#44; large amplitude of spikes and irregular rhythm&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> We used this information to estimate the length of high-quality STN activity detected along each channel&#46; In case of poor MER results&#44; lack of motor benefit&#44; or presence of adverse effects in the original three trajectories &#40;central&#44; anterior and lateral&#41;&#44; 2 additional cannulas in the medial and posterior channels were implanted in order to probe the quality of these regions&#46; The channel and the final depth of implantation &#40;defined as position of the lowermost contact&#41; of each electrode were decided based on MER and macrostimulation test results&#46; In our cohort&#44; most patients received Activa&#8482; PC or Percept&#8482; PC &#40;Medtronic&#44; USA&#41; IPGs&#44; while a few received Vercise&#8482; PC &#40;Boston Scientific&#44; USA&#41; IPGs&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">After the surgery&#44; a CT scan was performed and fused with the preoperative MRI to evaluate the final position of the electrodes and exclude complications such as haemorrhage or ischaemia&#46; In this study&#44; this same analysis was repeated at least a month after the surgery&#44; making use of the FrameLink StealthStation 8&#174; software to determine the final coordinates of the tip of the electrode &#40;shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Statistical analysis and graphs were performed using GraphPad Prism &#40;Version 9&#46;0&#46;0&#44; GraphPad Software&#44; San Diego&#44; California&#44; USA&#41; and IBM SPSS Statistics for Windows &#40;Version 27&#46;0&#44; IBM&#44; Armonk&#44; New York&#44; USA&#41;&#46; The Kolmogorov&#8211;Smirnov test was used to assess if the data had a normal distribution&#46; McNemar&#39;s test was used to analyze differences in the chosen electrode trajectory &#40;central vs&#46; non-central&#41; between the first and second sides&#44; and the left and right hemispheres&#46; Using the initially planned coordinates from saved surgery plans&#44; and the final electrode locations&#44; the Euclidean vector deviation was calculated using Pythagoras&#8217; theorem applied to three-dimensional space&#46; Displacements in the <span class="elsevierStyleItalic">x</span>-&#44; <span class="elsevierStyleItalic">y</span>- and <span class="elsevierStyleItalic">z</span>-directions were calculated by subtracting final and planned coordinates in each respective plane&#46; Paired <span class="elsevierStyleItalic">t</span>-test was then used to evaluate differences between the first and second sides&#46; Regarding the length of high-quality STN activity on each channel&#44; comparisons were done using the Wilcoxon matched-pairs signed-rank test&#46; Categorical variables were expressed as percentages and continuous variables as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; The level of significance considered was <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study population</span><p id="par0055" class="elsevierStylePara elsevierViewall">Of the 52 patients who received bilateral DBS surgery between January 2019 and February 2021&#44; only 30 patients &#40;60 implanted electrodes&#41; fulfilled all the criteria and were included in this study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Sixteen &#40;53&#37;&#41; of the patients were female&#44; the mean age at the time of surgery was 62&#46;43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;63 years and the mean duration of disease was 11&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;74 years&#46; The mean UPDRS-III score off medication before surgery was 54&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;8&#46; One month after surgery&#44; the mean UPDRS-III score off medication and with stimulation switched on was 13&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;49&#46; Sixteen patients &#40;53&#37;&#41; had the first electrode implanted on the right side &#40;shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Electrode trajectories</span><p id="par0065" class="elsevierStylePara elsevierViewall">Overall&#44; the central channel was the most often used&#44; in a total of 33 electrodes &#40;55&#37;&#41;&#44; followed by the anterior channel&#44; chosen for 21 electrodes &#40;35&#37;&#41;&#46; The lateral channel was used in 4 cases and the medial in 2&#46; The trajectory used for the implantation of the electrodes was symmetrical in 43&#37; of patients&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a and b&#44; the final leads were implanted in the central channel more frequently on the first side&#58; in 21 patients &#40;70&#46;0&#37;&#41; for the first side and in 12 patients &#40;40&#46;0&#37;&#41; for the second &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;022&#41;&#46; Furthermore&#44; regarding the first implanted side&#44; the anterior channel was chosen in 7 patients &#40;23&#46;3&#37;&#41;&#44; while the lateral and medial channels were chosen in only 1 patient each&#46; Concerning the second side&#44; the anterior channel was used in 14 patients &#40;46&#46;7&#37;&#41;&#44; the lateral in 3 &#40;10&#46;0&#37;&#41; and the medial in 1 &#40;3&#46;33&#37;&#41;&#46; Cases where the medial channel was chosen were due to the low threshold for adverse effects in the other channels&#46; The posterior channel was never used on either side&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">When comparing the electrode trajectories chosen on the left and right cerebral hemispheres&#44; regardless of which side was first implanted&#44; the central channel was chosen in 60&#37; and 50&#37; of the cases&#44; the anterior in 23&#46;3&#37; and 46&#46;7&#37;&#44; and the lateral in 10&#46;0&#37; and 3&#46;33&#37;&#44; respectively&#46; The medial channel was only used in the left hemisphere&#46; The differences between both hemispheres were not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;58&#59; shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>c and d&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">STN activity detected by MER</span><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the first side&#44; MER activity was observed in at least one channel in all patients&#59; however&#44; there were 5 patients where not all channels were tested &#40;1 anterior&#44; 3 lateral&#44; and 1 anterior and lateral&#41;&#46; On the second side&#44; all channels were tested in every patient&#44; but there were 3 cases where there was no high-quality MER activity in any of them&#46; In these situations&#44; the final trajectories chosen were based on the macrostimulation test results alone&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The mean length of high-quality STN activity recorded in each channel is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; For the central channel&#44; the first side showed a longer length of activity than the second&#44; but the difference wasn&#8217;t significant &#40;3&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;85<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 2&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94<span class="elsevierStyleHsp" style=""></span>mm&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;539&#41;&#46; On the other hand&#44; the second side showed a significant increase in activity on the anterior channel when compared to the first &#40;2&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;14<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 1&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;07<span class="elsevierStyleHsp" style=""></span>mm&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0367&#41;&#46; In the lateral channel&#44; both sides had a similar length of STN activity &#40;2&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94<span class="elsevierStyleHsp" style=""></span>mm on the first side vs&#46; 2&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;97<span class="elsevierStyleHsp" style=""></span>mm on the second&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;775&#41;&#46; However&#44; the final trajectory chosen did not always coincide with the channel that showed the longest MER activity&#44; as this decision was also influenced by the results of intraoperative macrostimulation&#46; The final trajectory chosen corresponded with the one with better MER results in 19 cases &#40;63&#37;&#41; on the first side and 17 cases &#40;57&#37;&#41; on the second side&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Planned versus final electrode position mismatch</span><p id="par0090" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; when comparing the 3D Euclidean vector deviation&#44; regardless of the direction of movement&#44; there was no statistically significant difference between both sides &#40;2&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;921<span class="elsevierStyleHsp" style=""></span>mm on the first side vs&#46; 2&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;37<span class="elsevierStyleHsp" style=""></span>mm on the second side&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0881&#41;&#46; However&#44; when comparing separate displacements in the <span class="elsevierStyleItalic">x</span>-&#44; <span class="elsevierStyleItalic">y</span>- and <span class="elsevierStyleItalic">z</span>-directions&#44; we found that electrodes implanted on the first side were placed on average 0&#46;178<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;917<span class="elsevierStyleHsp" style=""></span>mm lateral&#44; 0&#46;126<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;10<span class="elsevierStyleHsp" style=""></span>mm posterior and 1&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;64<span class="elsevierStyleHsp" style=""></span>mm inferior to the planned target&#44; while the electrodes placed on the second side were 0&#46;251<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;08<span class="elsevierStyleHsp" style=""></span>mm medial&#44; 0&#46;355<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;29<span class="elsevierStyleHsp" style=""></span>mm anterior and 2&#46;26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;47<span class="elsevierStyleHsp" style=""></span>mm inferior to the initial target &#40;shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>a and b&#41;&#46; The differences in deviation in the <span class="elsevierStyleItalic">y</span>-direction and <span class="elsevierStyleItalic">z</span>-direction were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0443 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0029&#44; respectively&#41;&#44; unlike those in the <span class="elsevierStyleItalic">x</span>-direction &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;104&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Electrode positioning</span><p id="par0095" class="elsevierStylePara elsevierViewall">Our results showed a tendency to opt for the central channel more frequently on the first side than on the second&#46; This difference was not attributable to a specific brain hemisphere&#44; but rather to the order by which the electrodes were implanted&#46; Two studies reported a similar trend&#44; with the central channel being used more on the first side than the second&#44; while the opposite occurred with the anterior channel&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">21&#44;23</span></a> Others showed that&#44; despite the central trajectory prevailing on both sides&#44; the percentage of cases where the anterior trajectory was chosen was higher on the second side&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">24&#8211;26</span></a> Conversely&#44; in a study by Umemura et al&#46;&#44; 21&#37; of the electrodes were placed in a trajectory other than the central&#46; In these cases&#44; the posterior channel was the most frequently chosen&#44; followed by the anterior channel&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> In another study&#44; MER results led to a medial and posterior correction of 35&#46;7&#37; of the original stereotactic coordinates obtained by CT-MRI image fusion&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> In these studies&#44; brain shift played a role in the differences observed&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">STN activity detected by MER</span><p id="par0100" class="elsevierStylePara elsevierViewall">In line with our initial hypothesis&#44; the mean length of high-quality STN activity detected in our cohort was larger in the central channel on the first side&#44; while in the anterior channel&#44; better recordings were obtained on the second side&#46; This supports the case for a lower accuracy in the final positioning of the second implanted electrode&#44; in relation to the initially planned target&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Planned versus final electrode position mismatch</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our results showed no statistically significant differences regarding the Euclidean vector displacement&#44; which is in agreement with results from other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;10</span></a> Nevertheless&#44; when analysing displacement in each axis&#44; we found a tendency for the second electrode to be positioned more anterior and inferior to the planned target than the first one&#44; further supporting our hypothesis&#46; Other studies reported similar results&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;7&#44;18</span></a> Slotty et al&#46; also showed that the highest median deviation on both sides was seen in the z-axis as it is prone to larger changes depending on the results of MER&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> In our cohort&#44; the larger deviation in the z-axis is probably due to the use of directional leads&#44; which must be implanted at a greater depth than the one initially planned to ensure that contacts are placed on the target&#46; Still&#44; it should be emphasized that changes in the depth of the electrode are not equal to changes in the <span class="elsevierStyleItalic">z</span>-axis&#46; Movement along the trajectory of the electrode will affect the target position in all axis&#44; depending on the angle of insertion&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Brain shift has been appointed as a cause for the differences observed between the first and second operated sides&#46; According to this hypothesis&#44; one would expect the STN on the second side to shift posteriorly and&#44; therefore&#44; lower quality MER activity on the anterior channel and&#44; consequently&#44; this trajectory to be chosen less frequently&#46; However&#44; our results show exactly the opposite pattern&#44; which is in line with studies that have shown that brain shift in subcortical structures is very limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#44;15</span></a> Supporting the external validity of our data&#44; two other studies have reported similar results&#44; with an increased use of anterior trajectories on the second side&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">21&#44;23</span></a> However&#44; they offer no probable explanation for this difference&#46; Chrastina et al&#46; reported that&#44; despite the central trajectory prevailing on both sides&#44; the anterior trajectory was still chosen more frequently on the second side than on the first&#46; They suggest that causes other than brain shift must play a role&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Consequently&#44; other factors beyond pneumocephalus should be taken into consideration&#46; A hypothesis is image distortion due to MRI&#44; since it does not provide an accurate representation of the electrophysiological boundaries of the STN&#44; therefore we should not rely solely on this information&#46; For this reason&#44; we fused MRI and CT images&#46; However&#44; since the pre-operative MRI is done with the patient supine&#44; the true position of the STN during surgery might no longer be accurately represented by the planned target&#44; as the patient is placed at a 30&#176; angle&#46; Additional sources of error include imaging discrepancies&#44; errors in target selection&#44; and vector calculations&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> Surgical factors&#44; such as dislocation or mechanical inaccuracy of the stereotactic frame&#44; misinterpretation of the MER data&#44; or factors related to the patient or the inherent disease&#44; such as age or disease duration&#44; can also play a role in these alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Study limitations</span><p id="par0120" class="elsevierStylePara elsevierViewall">The present study has some limitations&#46; First&#44; its retrospective nature and the small sample size mean that any extrapolations from our findings should be taken with caution&#44; although the high consistency between our electrophysiological and anatomical approaches provides an important degree of robustness to our conclusions&#46; Second&#44; the identification of the final electrode position was done manually&#44; by direct visualization in post-operative CT scans&#46; This too can be a source of error&#44; as the diameter of the leads is 1&#46;27<span class="elsevierStyleHsp" style=""></span>mm&#44; but the artefact can measure up to 3&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#44; hindering the identification of the centre of the most distal tip of the lead&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a> Furthermore&#44; the CT scan images used have a slice thickness of 1<span class="elsevierStyleHsp" style=""></span>mm so any values below this cannot be considered accurate&#46; Third&#44; the stereotactic techniques used can be responsible for a Euclidean distance of up to 2<span class="elsevierStyleHsp" style=""></span>mm between the planned target and the final lead location&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> though more recent methods managed to obtain deviations smaller than 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a> Our results fit this range of values&#44; despite being larger than those obtained by some other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;31</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Future studies should be conducted to compare electrode displacement between the planned target and the electrode artefact in immediate and in delayed post-operative images&#44; as well as to evaluate the clinical significance of the differences observed&#44; by comparing the preoperative and postoperative UPDRS-III scores on each implanted side&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusion</span><p id="par0130" class="elsevierStylePara elsevierViewall">This study showed that in bilateral STN-DBS there is a tendency for the placement of the first implanted electrode to be more accurate and for the second electrode to have a statistically significant deviation in the anterior and inferior directions&#46; The initial target planning could possibly benefit from previously placing the second electrode more anteriorly&#44; therefore reducing the number of MER trajectories tested and&#44; hence&#44; the duration of the surgery&#46; Additionally&#44; these results suggest that brain shift cannot be considered the main cause for the differences observed in our cohort&#46; Further studies&#44; with larger sample sizes and prospective designs&#44; are required to analyze the role played by other factors&#46; Nevertheless&#44; our findings should be taken into account during planning for the second implanted side&#44; in order to achieve greater accuracy in the placement of electrodes&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">Nothing to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Deep brain stimulation &#40;DBS&#41; of the subthalamic nucleus &#40;STN&#41; is a recognized treatment for drug-refractory Parkinson&#39;s disease &#40;PD&#41;&#46; However&#44; the therapeutic success depends on the accuracy of targeting&#46; This study aimed to evaluate potential accuracy differences in the placement of the first and second electrodes implanted&#44; by comparing chosen electrode trajectories&#44; STN activity detected during microelectrode recording &#40;MER&#41;&#44; and the mismatch between the initially planned and final electrode positions on each side&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this retrospective cohort study&#44; we analyzed data from 30 patients who underwent one-stage bilateral DBS&#46; For most patients&#44; three arrays of microelectrodes were used to determine the physiological location of the STN&#46; Final target location depended also on the results of intraoperative stimulation&#46; The choice of central versus non-central channels was compared&#46; The Euclidean vector deviation was calculated using the initially planned coordinates and the final position of the tip of the electrode according to a CT scan taken at least a month after the surgery&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The central channel was chosen in 70&#37; of cases on the first side and 40&#37; of cases on the second side&#46; The mean length of high-quality STN activity recorded in the central channel was longer on the first side than the second &#40;3&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;85<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 2&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; while in the anterior channel there were better MER recordings on the second side &#40;1&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;07<span class="elsevierStyleHsp" style=""></span>mm on the first side vs&#46; 2&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;14<span class="elsevierStyleHsp" style=""></span>mm on the second&#41;&#46; Regarding the mismatch between planned versus final electrode position&#44; electrodes on the first side were placed on average 0&#46;178<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;917<span class="elsevierStyleHsp" style=""></span>mm lateral&#44; 0&#46;126<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;10<span class="elsevierStyleHsp" style=""></span>mm posterior and 1&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;64<span class="elsevierStyleHsp" style=""></span>mm inferior to the planned target&#44; while the electrodes placed on the second side were 0&#46;251<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;08<span class="elsevierStyleHsp" style=""></span>mm medial&#44; 0&#46;355<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;29<span class="elsevierStyleHsp" style=""></span>mm anterior and 2&#46;26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;47<span class="elsevierStyleHsp" style=""></span>mm inferior to the planned target&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There was a tendency for the anterior trajectory to be chosen more frequently than the central on the second side&#46; There was also a statistically significant deviation of the second electrodes in the anterior and inferior directions&#44; when compared to the electrodes on the first side&#44; suggesting that another cause other than brain shift may be responsible&#46; We should therefore factor this during planning for the second implanted side&#46; It might be useful to plan the second side more anteriorly&#44; possibly reducing the number of MER trajectories tested and the duration of surgery&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La estimulaci&#243;n cerebral profunda &#40;ECP&#41; del n&#250;cleo subtal&#225;mico &#40;NST&#41; es reconocida como un tratamiento para la enfermedad de Parkinson &#40;EP&#41; refractaria al tratamiento farmacol&#243;gico&#46; Sin embargo&#44; el &#233;xito de esta intervenci&#243;n depende de la precisi&#243;n de la colocaci&#243;n de los electrodos&#46; Este estudio tuvo como objetivo evaluar las posibles diferencias de precisi&#243;n entre la colocaci&#243;n del primer y segundo electrodo&#44; comparando las trayectorias elegidas para cada lado&#44; la actividad del NST detectada durante el microrregistro &#40;MER&#41; y la discrepancia entre las posiciones inicialmente planeadas y las finales&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En este estudio retrospectivo analizamos datos de 30 pacientes sometidos a ECP bilateral&#46; En la mayor&#237;a de los casos se usaron tres conjuntos de microelectrodos para determinar la ubicaci&#243;n fisiol&#243;gica del NST&#46; El posicionamiento final del electrodo estuvo asimismo condicionado por los resultados de la estimulaci&#243;n intraoperatoria&#46; Se compar&#243; la elecci&#243;n de canales centrales vs&#46; no centrales&#46; El vector euclidiano del desv&#237;o se calcul&#243; a partir de las coordenadas planeadas inicialmente y la posici&#243;n final de la punta del electrodo&#44; seg&#250;n una tomograf&#237;a computarizada realizada al menos un mes despu&#233;s de la cirug&#237;a&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La trayectoria central se eligi&#243; en 70&#37; de los casos en el primer lado y en el 40&#37; de los casos en el segundo lado&#46; La duraci&#243;n media de la actividad de alta calidad del NST registrada en el canal central fue mayor en el primer lado que en el segundo &#40;3&#44;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;85<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 2&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;94<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; mientras que en el canal anterior hubo mejores registros de MER en el segundo lado &#40;1&#44;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;07<span class="elsevierStyleHsp" style=""></span>mm en el primer lado vs&#46; 2&#44;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;14<span class="elsevierStyleHsp" style=""></span>mm en el segundo&#41;&#46; En cuanto a la discrepancia entre la diana planeada y la posici&#243;n final de los electrodos&#44; los electrodos del primer lado se colocaron&#44; por t&#233;rmino medio&#44; 0&#44;178<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;917<span class="elsevierStyleHsp" style=""></span>mm laterales&#44; 0&#44;126<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;10<span class="elsevierStyleHsp" style=""></span>mm posteriores y 1&#44;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;64<span class="elsevierStyleHsp" style=""></span>mm inferiores al objetivo&#44; mientras que los electrodos colocados en el segundo lado estaban 0&#44;251<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;08<span class="elsevierStyleHsp" style=""></span>mm mediales&#44; 0&#44;355<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;29<span class="elsevierStyleHsp" style=""></span>mm anteriores y 2&#44;26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;47<span class="elsevierStyleHsp" style=""></span>mm inferiores al objetivo planificado&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En el segundo lado&#44; observamos una tendencia a elegir la trayectoria anterior mas frecuentemente que la central&#46; Tambi&#233;n hubo un desv&#237;o estad&#237;sticamente significativo de los segundos electrodos&#44; en direcci&#243;n anterior e inferior&#44; en comparaci&#243;n con los electrodos del primer lado&#44; lo que sugiere que la causa puede ser otra que no el <span class="elsevierStyleItalic">brain shift</span>&#46; Por lo tanto&#44; debemos tener esto en cuenta al planear la inserci&#243;n del electrodo en el segundo lado&#46; Podr&#237;a ser &#250;til planear el segundo lado m&#225;s anteriormente&#44; posiblemente reduciendo el n&#250;mero de trayectorias probadas por MER y la duraci&#243;n de la cirug&#237;a&#46;</p></span>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mean distance<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD between the planned target and the final electrode position in the <span class="elsevierStyleItalic">x</span>- and <span class="elsevierStyleItalic">y</span>-planes &#40;a&#41; and in the <span class="elsevierStyleItalic">y</span>- and <span class="elsevierStyleItalic">z</span>-planes &#40;b&#41;&#44; on the first and second sides&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16 &#40;53&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Age at the time of surgery&#44; mean years<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of disease&#44; mean years<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with right side as first implanted side&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;53&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UPDRS-III med-off before surgery&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UPDRS-III med-off 1 month after surgery&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First side&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Second side&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Central channel&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean length&#44; mm<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;539&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No STN activity&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Anterior channel&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean length&#44; mm<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0367&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No STN activity&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Lateral channel&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean length&#44; mm<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;775&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No STN activity&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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