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Ghimire S, Thapa B, Neupane D, Pokharel P. Outcomes of stereotactic thalamotomy in patients of essential tremor: A systematic review. J Clin Neurosci 2024; 126:38-45. [PMID: 38824802 DOI: 10.1016/j.jocn.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 05/18/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Essential tremor is a neurological condition associated with movement disorder with more prevalence among adult group of population. The burden of essential tremor is peaking globally but with the advancement in the area of functional neurosurgery such as stereotactic thalamotomy, the quality of life of such patients can be improved drastically. METHODS This systemic review was conducted in accordance to the guidance of preferred Reporting items for Systematic Review and Meta-Analysis(PRISMA). Databases of "PubMed", "Embase", "Web of Science", "Cinhal Plus", and "Scopus" from inception till 2023 was undertaken. A combination of keywords, Medical Subject Headings (MeSH), and search terms such as Search strategy for PubMed search was as follows: "stereotactic thalamotomy" AND "essential tremor". RESULTS This systematic review analyzed 9 studies with a total of 274 patients of essential tremor patients. Unilateral thalamotomy was carried out among 268 patients and bilateral thalamotomy in rest of the patients. Vim and Vom nucleus were the site of thalamotmy with ventral intermedius nucleus being the major one. Ten different types of clinical tremor rating scales were used to assess pre operative and post operative improvement in the tremor scales of the individual patients. Dysarthria and limb weakness was noted post operative complication in majority of the cases. CONCLUSION Our study revealed that stereotactic thalamotomy provided good functional outcome in patients of essential tremor who underwent unilateral thalamotomy compared to bilateral thalamotomy. The positive outcome outweighs the complications in such functional surgery.
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Affiliation(s)
- Sagun Ghimire
- Department of Neurosurgery, B and B Hospital, Gwarko, Lalitpur, Nepal.
| | - Bibechan Thapa
- Department of Surgery, West Hertfordshire Teaching Hospital, United Kingdom
| | - Durga Neupane
- B.P. Koirala Institute of Health Science, Dharan, Nepal
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Neudorfer C, Kultas-Ilinsky K, Ilinsky I, Paschen S, Helmers AK, Cosgrove GR, Richardson RM, Horn A, Deuschl G. The role of the motor thalamus in deep brain stimulation for essential tremor. Neurotherapeutics 2024; 21:e00313. [PMID: 38195310 PMCID: PMC11103222 DOI: 10.1016/j.neurot.2023.e00313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/10/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024] Open
Abstract
The advent of next-generation technology has significantly advanced the implementation and delivery of Deep Brain Stimulation (DBS) for Essential Tremor (ET), yet controversies persist regarding optimal targets and networks responsible for tremor genesis and suppression. This review consolidates key insights from anatomy, neurology, electrophysiology, and radiology to summarize the current state-of-the-art in DBS for ET. We explore the role of the thalamus in motor function and describe how differences in parcellations and nomenclature have shaped our understanding of the neuroanatomical substrates associated with optimal outcomes. Subsequently, we discuss how seminal studies have propagated the ventral intermediate nucleus (Vim)-centric view of DBS effects and shaped the ongoing debate over thalamic DBS versus stimulation in the posterior subthalamic area (PSA) in ET. We then describe probabilistic- and network-mapping studies instrumental in identifying the local and network substrates subserving tremor control, which suggest that the PSA is the optimal DBS target for tremor suppression in ET. Taken together, DBS offers promising outcomes for ET, with the PSA emerging as a better target for suppression of tremor symptoms. While advanced imaging techniques have substantially improved the identification of anatomical targets within this region, uncertainties persist regarding the distinct anatomical substrates involved in optimal tremor control. Inconsistent subdivisions and nomenclature of motor areas and other subdivisions in the thalamus further obfuscate the interpretation of stimulation results. While loss of benefit and habituation to DBS remain challenging in some patients, refined DBS techniques and closed-loop paradigms may eventually overcome these limitations.
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Affiliation(s)
- Clemens Neudorfer
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | | | - Igor Ilinsky
- Department of Anatomy and Cell Biology, The University of Iowa, Iowa City, IA, USA
| | - Steffen Paschen
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | | | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Mark Richardson
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas Horn
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
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Ferreira Felloni Borges Y, Cheyuo C, Lozano AM, Fasano A. Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound. Expert Rev Neurother 2023; 23:603-619. [PMID: 37288812 DOI: 10.1080/14737175.2023.2221789] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered. AREAS COVERED In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion. EXPERT OPINION DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.
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Affiliation(s)
- Yuri Ferreira Felloni Borges
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
- Department of Parkinson's Disease & Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital, Gravedona Ed Uniti, Como, Italy
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Blomstedt Y, Stenmark Persson R, Awad A, Hariz G, Philipson J, Hariz M, Fytagoridis A, Blomstedt P. 10 Years Follow-Up of Deep Brain Stimulation in the Caudal Zona Incerta/Posterior Subthalamic Area for Essential Tremor. Mov Disord Clin Pract 2023; 10:783-793. [PMID: 37205250 PMCID: PMC10187013 DOI: 10.1002/mdc3.13729] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/18/2023] [Accepted: 03/03/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Long-term data on the effects of deep brain stimulation (DBS) for essential tremor (ET) is scarce, especially regarding DBS in the caudal Zona incerta (cZi) and the posterior subthalamic area (PSA). OBJECTIVES The aim of this prospective study was to evaluate the effect of cZi/PSA DBS in ET at 10 years after surgery. METHODS Thirty-four patients were included. All patients received cZi/PSA DBS (5 bilateral/29 unilateral) and were evaluated at regular intervals using the essential tremor rating scale (ETRS). RESULTS One year after surgery, there was a 66.4% improvement of total ETRS and 70.7% improvement of tremor (items 1-9) compared with the preoperative baseline. Ten years after surgery, 14 patients had died and 3 were lost to follow-up. In the remaining 17 patients, a significant improvement was maintained (50.8% for total ETRS and 55.8% for tremor items). On the treated side the scores of hand function (items 11-14) had improved by 82.6% at 1 year after surgery, and by 66.1% after 10 years. Since off-stimulation scores did not differ between year 1 and 10, this 20% deterioration of on-DBS scores was interpreted as a habituation. There was no significant increase in stimulation parameters beyond the first year. CONCLUSIONS This 10 year follow up study, found cZi/PSA DBS for ET to be a safe procedure with a mostly retained effect on tremor, compared to 1 year after surgery, and in the absence of increase in stimulation parameters. The modest deterioration of effect of DBS on tremor was interpreted as habituation.
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Affiliation(s)
- Yulia Blomstedt
- Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
| | | | - Amar Awad
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
- Department of Integrative Medical Biology, Physiology SectionUmeå UniversityUmeåSweden
| | - Gun‐Marie Hariz
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
| | - Johanna Philipson
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
| | - Marwan Hariz
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
- UCL Institute of Neurology, Queen SquareLondonUK
| | | | - Patric Blomstedt
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
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Österlund E, Blomstedt P, Fytagoridis A. Ipsilateral Effects of Unilateral Deep Brain Stimulation for Essential Tremor. Stereotact Funct Neurosurg 2022; 100:248-252. [PMID: 35760039 DOI: 10.1159/000525325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 05/06/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Essential tremor (ET) is the most common adult movement disorder. For the relatively large group of patients who do not respond adequately to pharmacological therapy, deep brain stimulation (DBS) is a well-established treatment option. Most ET patients will have bilateral symptoms, and many of them receive bilateral DBS. Unilateral DBS is however still the most common procedure, and some papers suggest an ipsilateral effect in these patients. OBJECTIVES The aim of this study was to analyze if there is an ipsilateral effect of DBS for ET. METHOD We retrospectively analyzed our patient cohort with DBS surgery from 1996 to 2017, selecting patients with ET that underwent surgery with unilateral DBS without previous DBS or lesional surgery. A total number of 68 patients (39 males, 29 females) were identified. The patients were evaluated twice: first, at a mean time of 12 months after surgery defined as short-term follow-up and then again at a mean time of 49 months after surgery defined as long-term follow-up, using the clinical rating scale for tremor (CRST). RESULTS The total CRST score was reduced from mean 49.5 points at baseline before surgery to 20.2 (p < 0.001) at short-term and 28.3 (p < 0.001) at long-term follow-up. Contralateral tremor was reduced from mean 6.1 to 0.4 (p < 0.001) and 1.2 (p < 0.001), respectively. Contralateral hand function was reduced from 11.5 to 2.6 (p < 0.001) and 4.6 (p < 0.001), respectively. Ipsilateral hand function scored 9 at baseline, 8.3 at 1 year, and then again 9.4 at long-term follow-up. Ipsilateral tremor scored 4.0 at baseline, 3.7 at 1 year, and 4.3 at long-term follow-up. Neither ipsilateral hand function nor ipsilateral tremor showed significant difference. CONCLUSIONS There was no difference in severity of ipsilateral tremor, neither at 1 year nor in the long term. We believe ipsilateral effects of DBS for ET merits limited consideration regarding decision-making or patient counseling before surgery.
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Affiliation(s)
- Erik Österlund
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institutet, Solna, Sweden
| | - Patric Blomstedt
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Fytagoridis
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institutet, Solna, Sweden
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Prakash P, Deuschl G, Ozinga S, Mitchell KT, Cheeran B, Larson PS, Merola A, Groppa S, Tomlinson T, Ostrem JL. Benefits and Risks of a Staged‐Bilateral VIM versus Unilateral VIM DBS for Essential Tremor. Mov Disord Clin Pract 2022; 9:775-784. [PMID: 35937489 PMCID: PMC9346253 DOI: 10.1002/mdc3.13490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/23/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Despite over 30 years of clinical experience, high‐quality studies on the efficacy of bilateral versus unilateral deep brain stimulation (DBS) of the ventral intermediate (VIM) nucleus of the thalamus for medically refractory essential tremor (ET) remain limited. Objectives To compare benefits and risks of bilateral versus unilateral VIM DBS using the largest ET DBS clinical trial dataset available to date. Methods Participants from the US St. Jude/Abbott pivotal ET DBS trial who underwent staged‐bilateral VIM implantation constituted the primary cohort in this sub‐analysis. Their assessments “on” DBS at six months after second‐side VIM DBS implantation were compared to the assessments six months after unilateral implantation. Two control cohorts of participants with unilateral implantation only were also used for between‐group comparisons. Results The primary cohort consisted of n = 38 ET patients (22M/16F; age of 65.3 ± 9.5 years). The second side VIM‐DBS resulted in a 29.6% additional improvement in the total motor CRST score (P < 0.001), with a 64.1% CRST improvement in the contralateral side (P < 0.001). An added improvement was observed in the axial tremor score (21.4%, P = 0.005), and CRST part B (24.8%, P < 0.001) score. Rate of adverse events was slightly higher after bilateral stimulation. Conclusions In the largest ET DBS study to date, staged‐bilateral VIM DBS was a highly effective treatment for ET with bilateral implantation resulting in greater reduction in total motor tremor scores when compared to unilateral stimulation alone.
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Affiliation(s)
- Prarthana Prakash
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center University of California San Francisco CA United States
| | - Guenther Deuschl
- Department of Neurology, Universitatsklinikum Schleswig‐Holstein, Kiel Campus Christian Albrechts University Kiel Kiel Germany
| | - Sarah Ozinga
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | | | - Binith Cheeran
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | - Paul S. Larson
- Department of Neurosurgery University of Arizona Tuscon AZ
| | - Aristide Merola
- Department of Neurology, Madden Center for Parkinson Disease and other Movement Disorders Ohio State University Wexner Medical Center Columbus OH United States
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience University Medical Center of the Johannes Gutenberg‐University Mainz Mainz Germany
| | - Tucker Tomlinson
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | - Jill L. Ostrem
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center University of California San Francisco CA United States
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Hayashi Y, Mishima T, Fujioka S, Morishita T, Inoue T, Nagamachi S, Tsuboi Y. Unilateral GPi-DBS Improves Ipsilateral and Axial Motor Symptoms in Parkinson’s Disease as Evidenced by a Brain Perfusion Single Photon Emission Computed Tomography Study. Front Hum Neurosci 2022; 16:888701. [PMID: 35634204 PMCID: PMC9130959 DOI: 10.3389/fnhum.2022.888701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Deep brain stimulation (DBS) is an effective treatment for advanced Parkinson’s disease (PD) with the targeting bilateral subthalamic nucleus or globus pallidus internus (STN or GPi-DBS). So far, detailed studies on the efficacy of unilateral STN-DBS for motor symptoms have been reported, but few studies have been conducted on unilateral GPi-DBS. Materials and Methods Seventeen patients with Parkinson’s disease (PwPD) who underwent unilateral GPi-DBS were selected. We conducted comparison analyses between scores obtained 6–42 months pre- and postoperatively using the following measurement tools: the Movement Disorder Society Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) part III, the Hoehn and Yahr stage, the presence/absence of dyskinesia, Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), Geriatric Depression Scale (GDS), levodopa equivalent dose (LED), and cerebral blood flow by single photon emission computed tomography (SPECT). Patient backgrounds were compared between four cohorts with favorable (good responders, ≥50% improvement) and unfavorable (poor responders, <50% improvement) postoperative outcome. Results Significant improvement was observed postoperatively in the following: total MDS-UPDRS Part III scores during the off period, contralateral scores, ipsilateral scores, and axial scores. Similarly, the Hoehn and Yahr stages during the off period, and GDS also showed significant decrease. In contrast, LED, MMSE, and FAB remained unchanged while the number of patients who scored positive for dyskinesia decreased by 40%. Abnormal cerebral blood flow preoperatively seen in the cerebral cortex had normalized in the total score-based good responder cohort. In the ipsilateral score-based good responder cohort, cerebral blood flow increased in the contralateral frontal lobe including in the premotor cortex, contralateral to the DBS. Compared to the poor responders, postoperative good responders demonstrated significantly higher preoperative MMSE scores. Discussion Unilateral GPi-DBS therapy was effective in improving contralateral, ipsilateral, and axial motor symptoms of patients with advanced PD; in particular, it was found to be especially beneficial in PwPD whose cognitive function was unimpaired; the treatment efficacy rivaled that of bilateral counterparts up till at least 6 months postoperatively. Finally, normalization of preoperative abnormalities in cerebral blood flow and increased cerebral blood flow in the contralateral frontal lobe indicated the beneficial potential of this therapy on ipsilateral motor symptoms.
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Affiliation(s)
- Yuka Hayashi
- Department of Neurology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takayasu Mishima
- Department of Neurology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
- *Correspondence: Takayasu Mishima,
| | - Shinsuke Fujioka
- Department of Neurology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takashi Morishita
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tooru Inoue
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shigeki Nagamachi
- Department of Radiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshio Tsuboi
- Department of Neurology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
- Yoshio Tsuboi,
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Wagle Shukla A. Reduction of neuronal hyperexcitability with modulation of T-type calcium channel or SK channel in essential tremor. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 163:335-355. [PMID: 35750369 DOI: 10.1016/bs.irn.2022.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Essential tremor is one of the most prevalent movement disorders. Propranolol and primidone are the first-line pharmacological therapies. They provide symptomatic control in less than 50% of patients. Topiramate, alprazolam, clonazepam, gabapentin, and botulinum toxin injections are the next line of treatments. These medications lead to modest improvements and are therefore commonly used as add-on agents. Surgical therapies, including deep brain stimulation (DBS) surgery and focused ultrasound beam targeted to the thalamus, are considered for treating tremor refractory to medications and lead to greater than 75% improvements in tremor symptoms. However, DBS is a costly and an invasive procedure; some patients report tolerance to benefits. Focused ultrasound therapy leading to brain lesions is associated with a possibility for permanent clinical deficits. Therefore, research efforts to develop the next generation of oral medications with greater benefits and lesser adverse effects are warranted. There is considerable evidence that the increased functions of calcium channels (P/Q-type and T-type channels) and reduced functions of calcium-activated potassium channels (SK channels) located in the neuronal membranes lead to tremor oscillations. Consequently, many new pharmacological studies have targeted these channels to leverage better clinical outcomes. The current review will discuss the pathophysiology, the specific importance of these channels, and the early clinical experience of using compounds targeting these channels to treat essential tremor.
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Affiliation(s)
- Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.
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Jameel A, Gedroyc W, Nandi D, Jones B, Kirmi O, Molloy S, Tai Y, Charlesworth G, Bain P. Double lesion MRgFUS treatment of essential tremor targeting the thalamus and posterior sub-thalamic area: preliminary study with two year follow-up. Br J Neurosurg 2021; 36:241-250. [PMID: 34382881 DOI: 10.1080/02688697.2021.1958150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND MR-guided focused ultrasound (MRgFUS) is an effective treatment for essential tremor (ET). However, the optimal intracranial target sites remain to be determined. OBJECTIVE To assess MRgFUS induced sequential lesions in (anterior-VIM/VOP nuclei) the thalamus and then posterior subthalamic area (PSA) performed during the same procedure for alleviating ET. METHODS 14 patients had unilateral MRgFUS lesions placed in anterior-VIM/VOP then PSA. Bain-Findley Spirals were collected during MRgFUS from the treated arm (BFS-TA) and throughout the study from the treated (BFS-TA) and non-treated (BFS-NTA) arms and scored by blinded assessors. Although, the primary outcome was change in the BFS-TA from baseline to 12 months we have highlighted the 24-month data. Secondary outcomes included the Clinical Rating Scale for Tremor (CRST), Quality of Life for ET (QUEST) and PHQ-9 depression scores. RESULTS The mean improvement in the BFS-TA from baseline to 24 months was 41.1% (p < 0.001) whilst BFS-NTA worsened by 8.8% (p < 0.001). Intra-operative BFS scores from the targeted arm showed a mean 27.9% (p < 0.001) decrease after anterior-VIM/VOP ablation and an additional 30.1% (p < 0.001) reduction from post anterior-VIM/VOP to post-PSA ablation. Mean improvements at 24 month follow-up in the CRST-parts A, B and C were 60.7%, 30.4% and 65.6% respectively and 37.8% in QUEST-tremor score (all p < 0.05). Unilateral tremor severity scores decreased in the treated arm (UETTS-TA) 72.9% (p = 0.001) and non-treated arm (UETTS-NTA) 30.5% (p = 0.003). At 24 months residual adverse effects were slight unsteadiness (n = 1) and mild hemi-chorea (n = 1). CONCLUSION Unilateral anterior-VIM/VOP and PSA MRgFUS significantly diminished contralateral arm tremor with improvements in arm function, tremor related disability and quality of life, with an acceptable adverse event profile.
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Affiliation(s)
- Ayesha Jameel
- Department of Radiology, St Maryent of Radi, St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Wladyslaw Gedroyc
- Department of Radiology, St Maryent of Radi, St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Dipankar Nandi
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - Bryn Jones
- Department of Radiology, St Maryent of Radi, St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Olga Kirmi
- Department of Radiology, St Maryent of Radi, St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Sophie Molloy
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - Yen Tai
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - Gavin Charlesworth
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - Peter Bain
- Division of Brain Sciences, Department of Neurosciences, Imperial College London, London, UK
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Opri E, Cernera S, Molina R, Eisinger RS, Cagle JN, Almeida L, Denison T, Okun MS, Foote KD, Gunduz A. Chronic embedded cortico-thalamic closed-loop deep brain stimulation for the treatment of essential tremor. Sci Transl Med 2021; 12:12/572/eaay7680. [PMID: 33268512 DOI: 10.1126/scitranslmed.aay7680] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/14/2020] [Accepted: 08/25/2020] [Indexed: 11/02/2022]
Abstract
Deep brain stimulation (DBS) is an approved therapy for the treatment of medically refractory and severe movement disorders. However, most existing neurostimulators can only apply continuous stimulation [open-loop DBS (OL-DBS)], ignoring patient behavior and environmental factors, which consequently leads to an inefficient therapy, thus limiting the therapeutic window. Here, we established the feasibility of a self-adjusting therapeutic DBS [closed-loop DBS (CL-DBS)], fully embedded in a chronic investigational neurostimulator (Activa PC + S), for three patients affected by essential tremor (ET) enrolled in a longitudinal (6 months) within-subject crossover protocol (DBS OFF, OL-DBS, and CL-DBS). Most patients with ET experience involuntary limb tremor during goal-directed movements, but not during rest. Hence, the proposed CL-DBS paradigm explored the efficacy of modulating the stimulation amplitude based on patient-specific motor behavior, suppressing the pathological tremor on-demand based on a cortical electrode detecting upper limb motor activity. Here, we demonstrated how the proposed stimulation paradigm was able to achieve clinical efficacy and tremor suppression comparable with OL-DBS in a range of movements (cup reaching, proximal and distal posture, water pouring, and writing) while having a consistent reduction in energy delivery. The proposed paradigm is an important step toward a behaviorally modulated fully embedded DBS system, capable of delivering stimulation only when needed, and potentially mitigating pitfalls of OL-DBS, such as DBS-induced side effects and premature device replacement.
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Affiliation(s)
- Enrico Opri
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA.
| | - Stephanie Cernera
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
| | - Rene Molina
- Electrical and Computer Engineering, University of Florida, Gainesville, FL 32603, USA
| | - Robert S Eisinger
- Norman Fixel Institute for Neurological Diseases at UF Health, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Jackson N Cagle
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
| | - Leonardo Almeida
- Norman Fixel Institute for Neurological Diseases at UF Health, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Timothy Denison
- Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
| | - Michael S Okun
- Norman Fixel Institute for Neurological Diseases at UF Health, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Kelly D Foote
- Norman Fixel Institute for Neurological Diseases at UF Health, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Aysegul Gunduz
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA.,Electrical and Computer Engineering, University of Florida, Gainesville, FL 32603, USA.,Norman Fixel Institute for Neurological Diseases at UF Health, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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11
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Kim MJ, Chang KW, Park SH, Chang WS, Jung HH, Chang JW. Stimulation-Induced Side Effects of Deep Brain Stimulation in the Ventralis Intermedius and Posterior Subthalamic Area for Essential Tremor. Front Neurol 2021; 12:678592. [PMID: 34177784 PMCID: PMC8220085 DOI: 10.3389/fneur.2021.678592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/03/2021] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation (DBS) targeting the ventralis intermedius (VIM) nucleus of the thalamus and the posterior subthalamic area (PSA) has been shown to be an effective treatment for essential tremor (ET). The aim of this study was to compare the stimulation-induced side effects of DBS targeting the VIM and PSA using a single electrode. Patients with medication-refractory ET who underwent DBS electrode implantation between July 2011 and October 2020 using a surgical technique that simultaneously targets the VIM and PSA with a single electrode were enrolled in this study. A total of 93 patients with ET who had 115 implanted DBS electrodes (71 unilateral and 22 bilateral) were enrolled. The Clinical Rating Scale for Tremor (CRST) subscores improved from 20.0 preoperatively to 4.3 (78.5% reduction) at 6 months, 6.3 (68.5% reduction) at 1 year, and 6.5 (67.5% reduction) at 2 years postoperation. The best clinical effect was achieved in the PSA at significantly lower stimulation amplitudes. Gait disturbance and clumsiness in the leg was found in 13 patients (14.0%) upon stimulation of the PSA and in significantly few patients upon stimulation of the VIM (p = 0.0002). Fourteen patients (15.1%) experienced dysarthria when the VIM was stimulated; this number was significantly more than that with PSA stimulation (p = 0.0233). Transient paresthesia occurred in 13 patients (14.0%) after PSA stimulation and in six patients (6.5%) after VIM stimulation. Gait disturbance and dysarthria were significantly more prevalent in patients undergoing bilateral DBS than in those undergoing unilateral DBS (p = 0.00112 and p = 0.0011, respectively). Paresthesia resolved either after reducing the amplitude or switching to bipolar stimulation. However, to control gait disturbance and dysarthria, some loss of optimal tremor control was necessary at that particular electrode contact. In the present study, the most common stimulation-induced side effect associated with VIM DBS was dysarthria, while that associated with PSA DBS was gait disturbance. Significantly, more side effects were associated with bilateral DBS than with unilateral DBS. Therefore, changing active DBS contacts to simultaneous targeting of the VIM and PSA may be especially helpful for ameliorating stimulation-induced side effects.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| | - Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - So Hee Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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12
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Giordano M, Caccavella VM, Zaed I, Foglia Manzillo L, Montano N, Olivi A, Polli FM. Comparison between deep brain stimulation and magnetic resonance-guided focused ultrasound in the treatment of essential tremor: a systematic review and pooled analysis of functional outcomes. J Neurol Neurosurg Psychiatry 2020; 91:1270-1278. [PMID: 33055140 DOI: 10.1136/jnnp-2020-323216] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
Abstract
The current gold standard surgical treatment for medication-resistant essential tremor (ET) is deep brain stimulation (DBS). However, recent advances in technologies have led to the development of incisionless techniques, such as magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy. The authors perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to compare unilateral MRgFUS thalamotomy to unilateral and bilateral DBS in the treatment of ET in terms of tremor severity and quality of life improvement. PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and SCOPUS databases were searched. 45 eligible articles, published between 1990 and 2019, were retrieved. 1202 patients were treated with DBS and 477 were treated with MRgFUS thalamotomy. Postoperative tremor improvement was greater following DBS than MRgFUS thalamotomy (p<0.001). A subgroup analysis was carried out stratifying by treatment laterality: bilateral DBS was significantly superior to both MRgFUS and unilateral DBS (p<0.001), but no significant difference was recorded between MRgFUS and unilateral DBS (p<0.198). Postoperative quality of life improvement was significantly greater following MRgFUS thalamotomy than DBS (p<0.001). Complications were differently distributed among the two groups (p<0.001). Persistent complications were significantly more common in the MRgFUS group (p=0.042). While bilateral DBS proves superior to unilateral MRgFUS thalamotomy in the treatment of ET, a subgroup analysis suggests that treatment laterality is the most significant determinant of tremor improvement, thus highlighting the importance of future investigations on bilateral staged MRgFUS thalamotomy.
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Affiliation(s)
- Martina Giordano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | | | - Ismail Zaed
- Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | - Nicola Montano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Filippo Maria Polli
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
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13
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Fasano A, Helmich RC. Tremor habituation to deep brain stimulation: Underlying mechanisms and solutions. Mov Disord 2019; 34:1761-1773. [PMID: 31433906 DOI: 10.1002/mds.27821] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022] Open
Abstract
DBS of the ventral intermediate nucleus is an extremely effective treatment for essential tremor, although a waning benefit is observed after a variable time in a variable proportion of patients (ranging from 0% to 73%), a concept historically defined as "tolerance." Tolerance is currently an established concept in the medical community, although there is debate on its real existence. In fact, very few publications have actually addressed the problem, thus making tolerance a typical example of science based on "eminence rather than evidence." The underpinnings of the phenomena associated with the progressive loss of DBS benefit are not fully elucidated, although the interplay of different-not mutually exclusive-factors has been advocated. In this viewpoint, we gathered the evidence explaining the progressive loss of benefit observed after DBS. We grouped these factors in three categories: disease-related factors (tremor etiology and progression); surgery-related factors (electrode location, microlesional effect and placebo); and stimulation-related factors (not optimized stimulation, stimulation-induced side effects, habituation, and tremor rebound). We also propose possible pathophysiological explanations for the phenomenon and define a nomenclature of the associated features: early versus late DBS failure; tremor rebound versus habituation (to be preferred over tolerance). Finally, we provide a practical approach for preventing and treating this loss of DBS benefit, and we draft a possible roadmap for the research to come. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Rick C Helmich
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, The Netherlands
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14
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Dallapiazza RF, Lee DJ, De Vloo P, Fomenko A, Hamani C, Hodaie M, Kalia SK, Fasano A, Lozano AM. Outcomes from stereotactic surgery for essential tremor. J Neurol Neurosurg Psychiatry 2019; 90:474-482. [PMID: 30337440 PMCID: PMC6581115 DOI: 10.1136/jnnp-2018-318240] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/17/2018] [Accepted: 09/25/2018] [Indexed: 11/03/2022]
Abstract
There are several different surgical procedures that are used to treat essential tremor (ET), including deep brain stimulation (DBS) and thalamotomy procedures with radiofrequency (RF), radiosurgery (RS) and most recently, focused ultrasound (FUS). Choosing a surgical treatment requires a careful presentation and discussion of the benefits and drawbacks of each. We conducted a literature review to compare the attributes and make an appraisal of these various procedures. DBS was the most commonly reported treatment for ET. One-year tremor reductions ranged from 53% to 63% with unilateral Vim DBS. Similar improvements were demonstrated with RF (range, 74%-90%), RS (range, 48%-63%) and FUS thalamotomy (range, 35%-75%). Overall, bilateral Vim DBS demonstrated more improvement in tremor reduction since both upper extremities were treated (range, 66%-78%). Several studies show continued beneficial effects from DBS up to five years. Long-term follow-up data also support RF and gamma knife radiosurgical thalamotomy treatments. Quality of life measures were similarly improved among patients who received all treatments. Paraesthesias, dysarthria and ataxia were commonly reported adverse effects in all treatment modalities and were more common with bilateral DBS surgery. Many of the neurological complications were transient and resolved after surgery. DBS surgery had the added benefit of programming adjustments to minimise stimulation-related complications. Permanent neurological complications were most commonly reported for RF thalamotomy. Thalamic DBS is an effective, safe treatment with a long history. For patients who are medically unfit or reluctant to undergo DBS, several thalamic lesioning methods have parallel benefits to unilateral DBS surgery. Each of these surgical modalities has its own nuance for treatment and patient selection. These factors should be carefully considered by both neurosurgeons and patients when selecting an appropriate treatment for ET.
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Affiliation(s)
| | - Darrin J Lee
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Philippe De Vloo
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Anton Fomenko
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Clement Hamani
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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15
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Avecillas-Chasin JM, Poologaindran A, Morrison MD, Rammage LA, Honey CR. Unilateral Thalamic Deep Brain Stimulation for Voice Tremor. Stereotact Funct Neurosurg 2019; 96:392-399. [PMID: 30625492 DOI: 10.1159/000495413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 11/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Voice tremor (VT) is the involuntary and rhythmical phonatory instability of the voice. Recent findings suggest that unilateral deep brain stimulation of the ventral intermediate nucleus (Vim-DBS) can sometimes be effective for VT. In this exploratory analysis, we investigated the effect of Vim-DBS on VT and tested the hypothesis that unilateral thalamic stimulation is effective for patients with VT. METHODS Seven patients with VT and previously implanted bilateral Vim-DBS were enrolled in the study. Each patient was randomized and recorded performing sustained phonation during the following conditions: left thalamic stimulation, right thalamic stimulation, bilateral thalamic stimulation (Bil-ON), and no stimulation (Bil-OFF). Perceptual VT ratings and an acoustic analysis to find the rate of variation of the fundamental frequency measured by the standard deviation of the pitch (f0SD) were performed in a blinded manner. For the purposes of this study, a "dominant" side was defined as one with more than twice as much reduction in VT following Vim-DBS compared to the contralateral side. The Wilcoxon signed-rank test was performed to compare the effect of the dominant side stimulation in the reduction of VT scores and f0SD. The volume of activated tissue (VAT) of the dominant stimulation side was modelled against the degree of improvement in VT to correlate the significant stimulation cluster with thalamic anatomy. Finally, tractography analysis was performed to analyze the connectivity of the significant stimulation cluster. RESULTS Unilateral stimulation was beneficial in all 7 patients. Five patients clearly had a "dominant" side with either benefit only seen following stimulation of one side or more than twice as much benefit from one side compared to the other. Two patients had similar benefit with unilateral stimulation from either side. The Wilcoxon paired test showed significant differences between unilateral dominant and unilateral nondominant stimulation for VT scores (p = 0.04), between unilateral dominant and Bil-OFF (p = 0.04), and between Bil-ON and unilateral nondominant stimulation (p = 0.04). No significant differences were found between Bil-ON and unilateral dominant condition (p = 0.27), or between Bil-OFF and unilateral nondominant (p = 0.23). The dominant VAT showed that the significant voxels associated with the best VT control were located in the most ventral and medial part of the Vim nucleus and the ventralis caudalis anterior internus nucleus. The connectivity analysis showed significant connectivity with the cortical areas of the speech circuit. CONCLUSIONS Unilateral dominant-side thalamic stimulation and bilateral thalamic stimulation were equally effective in reducing VT. Nondominant unilateral stimulation alone did not significantly improve VT.
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Affiliation(s)
- Josue M Avecillas-Chasin
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Anujan Poologaindran
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Murray D Morrison
- Department of Surgery, Division of Otolaryngology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Linda A Rammage
- Department of Surgery, Division of Otolaryngology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada,
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16
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Benefits and risks of unilateral and bilateral ventral intermediate nucleus deep brain stimulation for axial essential tremor symptoms. Parkinsonism Relat Disord 2018; 60:126-132. [PMID: 30220556 DOI: 10.1016/j.parkreldis.2018.09.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/09/2018] [Accepted: 09/04/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Many experts assume bilateral deep brain stimulation (DBS) is necessary to improve axial tremor in essential tremor (ET). In the largest clinical trial of DBS for ET to date evaluating a non-directional, constant current device, we studied the effects of unilateral and staged bilateral DBS on axial tremor. METHODS We included all participants from the original trial with unilateral ventral intermediate nucleus (VIM) DBS and 90-day follow up at minimum. Primary outcomes were changes in pooled axial subscores in the Clinical Rating Scale for Tremor (CRST) at 90 and 180 days after activation of unilateral VIM DBS compared to pre-operative baseline (n=119). Additionally, we performed within-subject analyses for unilateral versus bilateral DBS at 180 days in the cohort who underwent staged surgery to bilateral DBS (n=39). RESULTS Unilateral VIM DBS improved midline tremor by 58% at 90 days (median[IQR]) (3[3] to 1[2], p<0.001) and 65% at 180 days (3[3] to 1[2], p<0.001) versus pre-op baseline. In the staged to bilateral DBS cohort, midline tremor scores further improved after bilateral DBS at 180 days by 63% versus unilateral DBS (3[3] to 1[3], p=0.007). There were, however, 35 additional DBS and surgery-related adverse events, 14 related to incoordination, gait impairment, or speech impairment, versus 6 after unilateral DBS. CONCLUSION Unilateral VIM DBS for ET significantly improved associated axial tremor. Staged bilateral DBS was associated with additional axial tremor improvement but also additional adverse events. Unilateral VIM DBS may be sufficient to achieve a goal of contralateral limb and axial tremor attenuation.
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17
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Alomar S, King NKK, Tam J, Bari AA, Hamani C, Lozano AM. Speech and language adverse effects after thalamotomy and deep brain stimulation in patients with movement disorders: A meta-analysis. Mov Disord 2018; 32:53-63. [PMID: 28124434 DOI: 10.1002/mds.26924] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The thalamus has been a surgical target for the treatment of various movement disorders. Commonly used therapeutic modalities include ablative and nonablative procedures. A major clinical side effect of thalamic surgery is the appearance of speech problems. OBJECTIVE This review summarizes the data on the development of speech problems after thalamic surgery. METHODS A systematic review and meta-analysis was performed using nine databases, including Medline, Web of Science, and Cochrane Library. We also checked for articles by searching citing and cited articles. We retrieved studies between 1960 and September 2014. RESULTS Of a total of 2,320 patients, 19.8% (confidence interval: 14.8-25.9) had speech difficulty after thalamotomy. Speech difficulty occurred in 15% (confidence interval: 9.8-22.2) of those treated with a unilaterally and 40.6% (confidence interval: 29.5-52.8) of those treated bilaterally. Speech impairment was noticed 2- to 3-fold more commonly after left-sided procedures (40.7% vs. 15.2%). Of the 572 patients that underwent DBS, 19.4% (confidence interval: 13.1-27.8) experienced speech difficulty. Subgroup analysis revealed that this complication occurs in 10.2% (confidence interval: 7.4-13.9) of patients treated unilaterally and 34.6% (confidence interval: 21.6-50.4) treated bilaterally. After thalamotomy, the risk was higher in Parkinson's patients compared to patients with essential tremor: 19.8% versus 4.5% in the unilateral group and 42.5% versus 13.9% in the bilateral group. After DBS, this rate was higher in essential tremor patients. CONCLUSION Both lesioning and stimulation thalamic surgery produce adverse effects on speech. Left-sided and bilateral procedures are approximately 3-fold more likely to cause speech difficulty. This effect was higher after thalamotomy compared to DBS. In the thalamotomy group, the risk was higher in Parkinson's patients, whereas in the DBS group it was higher in patients with essential tremor. Understanding the pathophysiology of speech disturbance after thalamic procedures is a priority. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Soha Alomar
- King Abdulaziz University, Department of Surgery, Division of Neurosurgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.,University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nicolas K K King
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Joseph Tam
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ausaf A Bari
- University of California Los Angeles, Department of Neurosurgery, Los Angeles, California, USA
| | - Clement Hamani
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andres M Lozano
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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18
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Eddelman D, Wewel J, Wiet RM, Metman LV, Sani S. Deep brain stimulation with a pre-existing cochlear implant: Surgical technique and outcome. Surg Neurol Int 2017; 8:47. [PMID: 28480109 PMCID: PMC5402338 DOI: 10.4103/sni.sni_412_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/03/2017] [Indexed: 11/09/2022] Open
Abstract
Background: Patients with previously implanted cranial devices pose a special challenge in deep brain stimulation (DBS) surgery. We report the implantation of bilateral DBS leads in a patient with a cochlear implant. Technical nuances and long-term interdevice functionality are presented. Case Description: A 70-year-old patient with advancing Parkinson's disease and a previously placed cochlear implant for sensorineural hearing loss was referred for placement of bilateral DBS in the subthalamic nucleus (STN). Prior to DBS, the patient underwent surgical removal of the subgaleal cochlear magnet, followed by stereotactic MRI, frame placement, stereotactic computed tomography (CT), and merging of imaging studies. This technique allowed for successful computational merging, MRI-guided targeting, and lead implantation with acceptable accuracy. Formal testing and programming of both the devices were successful without electrical interference. Conclusion: Successful DBS implantation with high resolution MRI-guided targeting is technically feasible in patients with previously implanted cochlear implants by following proper precautions.
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Affiliation(s)
- Daniel Eddelman
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Joshua Wewel
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - R Mark Wiet
- Department of Otolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Leo V Metman
- Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA
| | - Sepehr Sani
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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19
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Ravikumar VK, Parker JJ, Hornbeck TS, Santini VE, Pauly KB, Wintermark M, Ghanouni P, Stein SC, Halpern CH. Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor. Mov Disord 2017; 32:1165-1173. [PMID: 28370272 DOI: 10.1002/mds.26997] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/22/2017] [Accepted: 03/05/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Essential tremor remains a very common yet medically refractory condition. A recent phase 3 study demonstrated that magnetic resonance-guided focused ultrasound thalamotomy significantly improved upper limb tremor. The objectives of this study were to assess this novel therapy's cost-effectiveness compared with existing procedural options. METHODS Literature searches of magnetic resonance-guided focused ultrasound thalamotomy, DBS, and stereotactic radiosurgery for essential tremor were performed. Pre- and postoperative tremor-related disability scores were collected from 32 studies involving 83 magnetic resonance-guided focused ultrasound thalamotomies, 615 DBSs, and 260 stereotactic radiosurgery cases. Utility, defined as quality of life and derived from percent change in functional disability, was calculated; Medicare reimbursement was employed as a proxy for societal cost. Medicare reimbursement rates are not established for magnetic resonance-guided focused ultrasound thalamotomy for essential tremor; therefore, reimbursements were estimated to be approximately equivalent to stereotactic radiosurgery to assess a cost threshold. A decision analysis model was constructed to examine the most cost-effective option for essential tremor, implementing meta-analytic techniques. RESULTS Magnetic resonance-guided focused ultrasound thalamotomy resulted in significantly higher utility scores compared with DBS (P < 0.001) or stereotactic radiosurgery (P < 0.001). Projected costs of magnetic resonance-guided focused ultrasound thalamotomy were significantly less than DBS (P < 0.001), but not significantly different from radiosurgery. CONCLUSIONS Magnetic resonance-guided focused ultrasound thalamotomy is cost-effective for tremor compared with DBS and stereotactic radiosurgery and more effective than both. Even if longer follow-up finds changes in effectiveness or costs, focused ultrasound thalamotomy will likely remain competitive with both alternatives. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
| | | | | | | | - Kim Butts Pauly
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Pejman Ghanouni
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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Wharen RE, Okun MS, Guthrie BL, Uitti RJ, Larson P, Foote K, Walker H, Marshall FJ, Schwalb J, Ford B, Jankovic J, Simpson R, Dashtipour K, Phibbs F, Neimat JS, Stewart RM, Peichel D, Pahwa R, Ostrem JL. Thalamic DBS with a constant-current device in essential tremor: A controlled clinical trial. Parkinsonism Relat Disord 2017; 40:18-26. [PMID: 28400200 DOI: 10.1016/j.parkreldis.2017.03.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/10/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study of thalamic deep brain stimulation (DBS) investigated whether a novel constant-current device improves tremor and activities of daily living (ADL) in patients with essential tremor (ET). METHODS A prospective, controlled, multicenter study was conducted at 12 academic centers. We investigated the safety and efficacy of unilateral and bilateral constant-current DBS of the ventralis intermedius (VIM) nucleus of the thalamus in patients with essential tremor whose tremor was inadequately controlled by medications. The primary outcome measure was a rater-blinded assessment of the change in the target limb tremor score in the stimulation-on versus stimulation-off state six months following surgery. Multiple secondary outcomes were assessed at one-year follow-up, including motor, mood, and quality-of-life measures. RESULTS 127 patients were implanted with VIM DBS. The blinded, primary outcome variable (n = 76) revealed a mean improvement of 1.25 ± 1.26 points in the target limb tremor rating scale (TRS) score in the arm contralateral to DBS (p < 0.001). Secondary outcome variables at one year revealed significant improvements (p ≤ 0.001) in quality of life, depression symptoms, and ADL scores. Forty-seven patients had a second contralateral VIM-DBS, and this group demonstrated reduction in second-sided tremor at 180 days (p < 0.001). Serious adverse events related to the surgery included infection (n = 3), intracranial hemorrhage (n = 3), and device explantation (n = 3). CONCLUSION Unilateral and bilateral constant-current VIM DBS significantly improves upper extremity tremor, ADL, quality of life, and depression in patients with severe ET.
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Affiliation(s)
- Robert E Wharen
- Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States.
| | - Michael S Okun
- Departments of Neurology and Neurosurgery, University of Florida College of Medicine and McKnight Brain Institute, University of Florida Center for Movement Disorders and Neurorestoration, 3450 Hull Road, 4th Floor, Gainesville, FL 32607, United States.
| | - Barton L Guthrie
- Department of Neurosurgery, University of Alabama Birmingham, School of Medicine, Department of Neurosurgery, 510 20th Avenue South, FOT 1038, Birmingham, AL 35234, United States.
| | - Ryan J Uitti
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States.
| | - Paul Larson
- Department of Neurological Surgery, University of California San Francisco, 1635 Divisadero Street, 5th Floor, Suite 520-530, San Francisco, CA 94115, United States.
| | - Kelly Foote
- Departments of Neurological Surgery, University of Florida College of Medicine and McKnight Brain Institute, University of Florida Center for Movement Disorders and Neurorestoration, 3450 Hull Road, 4th Floor, Gainesville, FL 32607, United States.
| | - Harrison Walker
- Department of Neurology, University of Alabama Birmingham, School of Medicine, 510 20th Avenue South, FOT 1038, Birmingham, AL 35234, United States.
| | - Frederick J Marshall
- Neurology Department, University of Rochester, 919 Westfall Rd., Bldg C, Suite 220, Rochester, NY 14618, United States.
| | - Jason Schwalb
- Movement Disorder and Comprehensive Epilepsy Centers, Henry Ford Medical Group, 6777 West Maple Road, West Bloomfield, MI 48322, United States.
| | - Blair Ford
- Movement Disorder Group, Columbia University Medical Center, 710 West 168th Street, 3rd Floor, #350, New York, NY 10032, United States.
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, 6550 Fannin Street, Suite 1801, Houston, TX 77030, United States.
| | - Richard Simpson
- Department of Neurosurgery, The Methodist Hospital Physician Organization, 6560 Fannin, Suite 944, Houston, TX 77030, United States.
| | - Khashayar Dashtipour
- Department of Neurology, Loma Linda University Medical Center, Division of Movement Disorders, 11370 Anderson St, Suite 2400, Loma Linda, CA 92354, United States.
| | - Fenna Phibbs
- Department of Neurology, Vanderbilt University, A-0118 Medical Center North, Nashville, TN 37232-2551, United States.
| | - Joseph S Neimat
- Department of Neurosurgery, Vanderbilt University, 1211 22nd Ave. S, Nashville, TN 37232, United States.
| | - R Malcolm Stewart
- Movement Disorder Center, Texas Health Presbyterian Dallas, 8200 Walnut Hill, Dallas, TX 75231, United States.
| | - DeLea Peichel
- Clinical Research Department, St. Jude Medical, 6901 Preston Road, Plano, TX 75024, United States.
| | - Rajesh Pahwa
- Parkinson's Disease and Movement Disorder Center, University of Kansas Medical Center, 3599 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160, United States.
| | - Jill L Ostrem
- Surgical Movement Disorders, Department of Neurology, University of California San Francisco and the San Francisco Veteran's Affairs Medical Center, 1635 Divisadero Street, 5th Floor, Suite 520-530, San Francisco, CA 94115, United States.
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Wagle Shukla A, Okun MS. State of the Art for Deep Brain Stimulation Therapy in Movement Disorders: A Clinical and Technological Perspective. IEEE Rev Biomed Eng 2016; 9:219-33. [PMID: 27411228 DOI: 10.1109/rbme.2016.2588399] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Deep brain stimulation (DBS) therapy is a widely used brain surgery that can be applied for many neurological and psychiatric disorders. DBS is American Food and Drug Administration approved for medication refractory Parkinson's disease, essential tremor and dystonia. Although DBS has shown consistent success in many clinical trials, the therapy has limitations and there are well-recognized complications. Thus, only carefully selected patients are ideal candidates for this surgery. Over the last two decades, there have been significant advances in clinical knowledge on DBS. In addition, the surgical techniques and technology related to DBS has been rapidly evolving. The goal of this review is to describe the current status of DBS in the context of movement disorders, outline the mechanisms of action for DBS in brief, discuss the standard surgical and imaging techniques, discuss the patient selection and clinical outcomes in each of the movement disorders, and finally, introduce the recent advancements from a clinical and technological perspective.
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