INTRODUCTION: Deep brain stimulation (DBS) of the internal globus pallidus (GPi) is a well-established, effective treatment for dystonia. Substantial variability of therapeutic success has been the one of the drivers of an ongoing debate about proper stimulation site and settings, with several indications of the notional sweet spot pointing to the lower GPi or even subpallidal area. METHODS: The presented patient-blinded, random-order study with cross-sectional verification against healthy controls enrolled 17 GPi DBS idiopathic, cervical or generalised dystonia patients to compare the effect of the stimulation in the upper and lower GPi area, with the focus on sensorimotor network connectivity and local activity measured using functional magnetic resonance. RESULTS: Stimulation brought both these parameters to levels closer to the state detected in healthy controls. This effect was much more pronounced during the stimulation in the lower GPi area or beneath it than in slightly higher positions, with stimulation-related changes detected by both metrics of interest in the sensorimotor cortex, striatum, thalamus and cerebellum. CONCLUSIONS: All in all, this study not only replicated the results of previous studies on GPi DBS as a modality restoring sensorimotor network connectivity and local activity in dystonia towards the levels in healthy population, but also showed that lower GPi area or even subpallidal structures, be it white matter or even small, but essential nodes in the zona incerta as nucleus basalis of Meynert, are important regions to consider when programming DBS in dystonia patients.

Department of Cybernetics Czech Technical University Prague Prague Czech Republic

Department of Neurology 1st Faculty of Medicine Charles University and General University Hospital Prague Kateřinská 30 120 00 Prague Czech Republic

Department of Neurology 1st Faculty of Medicine Charles University and General University Hospital Prague Kateřinská 30 120 00 Prague Czech Republic; Center for Magnetic Resonance Research University of Minnesota Minneapolis MN USA; Department of Cybernetics Czech Technical University Prague Prague Czech Republic

Department of Neurology 1st Faculty of Medicine Charles University and General University Hospital Prague Kateřinská 30 120 00 Prague Czech Republic; Max Planck Institute for Human Cognitive and Brain Sciences Leipzig Germany

Department of Radiology Na Homolce Hospital Prague Czech Republic; 3rd Faculty of Medicine Charles University Prague Prague Czech Republic

Department of stereotactic and radiation neurosurgery Nemocnice Na Homolce Prague Czech Republic

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