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Nabiullina DI, Galimova RM, Illarioshkin SN, Buzaev IV, Safin SM, Akhmadeeva GN, Mukhamadeeva NR, Krekotin DK. [Experience of staged and simultaneous bilateral thalamotomy using MR-guided focused ultrasound in the treatment of essential tremor]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:65-73. [PMID: 37490667 DOI: 10.17116/jnevro202312307165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To show that effective and safe bilateral MR-guided focused ultrasound (MRgFUS) treatment of essential tremor (ET) is achievable. MATERIAL AND METHODS Four male patients underwent bilateral thalamotomy. Two patients underwent staged thalamotomy, with the ≥12 month interval between operations. Two patients underwent simultaneous bilateral thalamotomy. RESULTS After six months, all patients noted a significant reduction in symptoms on both sides: when assessing tremors with the Clinical Rating Scale for Tremor, the severity of hyperkinesis decreased by 57.5-69.7%. We did not observe any complications in any of the cases. CONCLUSION Our experience indicates that simultaneous bilateral MRI-guided focused ultrasound treatment of ET can be performed safely and effectively. Further research is necessary to estimate the effectiveness and adverse effect rates.
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Affiliation(s)
- D I Nabiullina
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
| | - R M Galimova
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
- Bashkir State Medical University, Ufa, Russia
| | | | - I V Buzaev
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
- Bashkir State Medical University, Ufa, Russia
| | - Sh M Safin
- Bashkir State Medical University, Ufa, Russia
| | - G N Akhmadeeva
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
| | - N R Mukhamadeeva
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
| | - D K Krekotin
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
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Murakami M, Horisawa S, Azuma K, Akagawa H, Nonaka T, Kawamata T, Taira T. Case Report: Long-Term Suppression of Paroxysmal Kinesigenic Dyskinesia After Bilateral Thalamotomy. Front Neurol 2021; 12:789468. [PMID: 34925221 PMCID: PMC8678037 DOI: 10.3389/fneur.2021.789468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Paroxysmal kinesigenic dyskinesia (PKD) is a movement disorder characterized by transient dyskinetic movements, including dystonia, chorea, or both, triggered by sudden voluntary movements. Carbamazepine and other antiepileptic drugs (AEDs) are widely used in the treatment of PKD, and they provide complete remission in 80–90% of medically treated patients. However, the adverse effects of AEDs include drowsiness and dizziness, which interfere with patients' daily lives. For those with poor compatibility with AEDs, other treatment approaches are warranted. Case Report: A 19-year-old man presented to our institute with right hand and foot dyskinesia. He had a significant family history of PKD; his uncle, grandfather, and grandfather's brother had PKD. The patient first experienced paroxysmal involuntary left hand and toe flexion with left forearm pronation triggered by sudden voluntary movements at the age of 14. Carbamazepine (100 mg/day) was prescribed, which led to a significant reduction in the frequency of attacks. However, carbamazepine induced drowsiness, which significantly interfered with his daily life, especially school life. He underwent right-sided ventro-oral (Vo) thalamotomy at the age of 15, which resulted in complete resolution of PKD attacks immediately after the surgery. Four months after the thalamotomy, he developed right elbow, hand, and toe flexion. He underwent left-sided Vo thalamotomy at the age of 19. Immediately after the surgery, the PKD attacks resolved completely. However, mild dysarthria developed, which spontaneously resolved within three months. Left-sided PKD attacks never developed six years after the right Vo thalamotomy, and right-sided PKD attacks never developed two years after the left Vo thalamotomy without medication. Conclusion: The present case showed long-term suppression of bilateral PKDs after bilateral thalamotomy, which led to drug-free conditions.
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Affiliation(s)
- Masato Murakami
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shiro Horisawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Kenko Azuma
- Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroyuki Akagawa
- Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Tokyo, Japan
| | - Taku Nonaka
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Fukutome K, Hirabayashi H, Osakada Y, Kuga Y, Ohnishi H. Bilateral Magnetic Resonance Imaging-Guided Focused Ultrasound Thalamotomy for Essential Tremor. Stereotact Funct Neurosurg 2021; 100:44-52. [PMID: 34515233 DOI: 10.1159/000518662] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Essential tremor is the most common movement disorder in adults. Bilateral symptoms are typical; however, bilateral thalamotomy for essential tremor is associated with a high probability of adverse events. We retrospectively investigated the efficacy and safety of staged bilateral ventral intermediate nucleus thalamotomy for refractory essential tremor using magnetic resonance imaging-guided focused ultrasound. METHODS We enrolled 5 consecutive patients with refractory essential tremor between September 2016 and March 2020. Patients underwent a second operation at least 1 year after the first operation. The second lesion was created asymmetrically to the first lesion. RESULTS Mean patient age was 57.6 years, and the mean interval between the 2 operations was 27.8 months. The second lesion center was superior to the first lesion in all patients. The mean baseline, second preoperative, and second postoperative Clinical Rating Scale for Tremor total scores were 63.6, 49.2, and 21.8, respectively. The mean baseline, second preoperative, and second postoperative Clinical Rating Scale for Tremor part C scores were 18.4, 8.2, and 2.6, respectively. One patient had permanent adverse events of slight dysarthria and discomfort in the tongue. No patient experienced dysphagia or cognitive dysfunction after the second operation. Four of the 5 patients were satisfied with the results of the bilateral treatment, including the patient who had permanent adverse events. CONCLUSIONS Magnetic resonance imaging-guided focused ultrasound is an effective method for bilateral thalamotomy when adhering to the following considerations: (1) asymmetrical lesions are created and (2) sufficient interval (>1 year) between operations.
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Affiliation(s)
- Kenji Fukutome
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan.,Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Hidehiro Hirabayashi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan.,Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Yosuke Osakada
- Department of Neurology, Ohnishi Neurological Center, Akashi, Japan
| | - Yoshihiro Kuga
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan
| | - Hideyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan
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Gallay MN, Moser D, Magara AE, Haufler F, Jeanmonod D. Bilateral MR-Guided Focused Ultrasound Pallidothalamic Tractotomy for Parkinson's Disease With 1-Year Follow-Up. Front Neurol 2021; 12:601153. [PMID: 33633664 PMCID: PMC7900542 DOI: 10.3389/fneur.2021.601153] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/05/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: Bilateral stereotactic neurosurgery for advanced Parkinson's disease (PD) has a long history beginning in the late 1940s. In view of improved lesioning accuracy and reduced bleeding risk and in spite of long-standing caveats about bilateral approaches, there is a need to investigate bilateral MR-guided focused ultrasound (MRgFUS) interventions. We hereby present the clinical results of bilateral pallidothalamic tractotomy (PTT), i.e., targeting of pallidal efferent fibers below the thalamus at the level of Forel's field H1, followed for 1 year after operation of the second side. Methods: Ten patients suffering from chronic and therapy-resistant PD having received bilateral PTT were followed for 1 year after operation of the second side. The primary endpoints included the Unified Parkinson's Disease Rating Scale (UPDRS) scores in on- and off-medication states, dyskinesias, dystonia, sleep disturbances, pain, reduction in drug intake, and assessment by the patient of her/his global symptom relief as well as tremor control. Results: The time frame between baseline UPDRS score and 1 year after the second side was 36 ± 15 months. The total UPDRS score off-medication at 1 year after the second PTT was reduced by 52% compared to that at baseline on-medication (p < 0.007). Percentage reductions of the mean scores comparing 1 year off- with baseline on-medication examinations were 91% for tremor (p = 0.006), 67% for distal rigidity (p = 0.006), and 54% for distal hypobradykinesia (p = 0.01). Gait and postural instability were globally unchanged to baseline (13% improvement of the mean, p = 0.67, and 5.3% mean reduction, p = 0.83). Speech difficulties, namely, hypophonia, tachyphemia, and initiation of speech, were increased by 58% (p = 0.06). Dyskinesias were suppressed in four over four, dystonia in four over five, and sleep disorders in three over four patients. There was 89% pain reduction. Mean L-Dopa intake was reduced from 690 ± 250 to 110 ± 190. Conclusions: Our results suggest an efficiency of bilateral PTT in controlling tremor, distal rigidity, distal hypobradykinesia, dyskinesias, dystonia, and pain when compared to best medical treatment at baseline. Larger series are of course needed.
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Affiliation(s)
- Marc N Gallay
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | - David Moser
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | - Anouk E Magara
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland.,Praxisgemeinschaft für Neurologie, Bern, Switzerland
| | - Fabio Haufler
- ETH Zürich, Department of Management, Technology, and Economics, Zurich, Switzerland
| | - Daniel Jeanmonod
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
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5
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Gallay MN, Moser D, Rossi F, Magara AE, Strasser M, Bühler R, Kowalski M, Pourtehrani P, Dragalina C, Federau C, Jeanmonod D. MRgFUS Pallidothalamic Tractotomy for Chronic Therapy-Resistant Parkinson's Disease in 51 Consecutive Patients: Single Center Experience. Front Surg 2020; 6:76. [PMID: 31993437 PMCID: PMC6971056 DOI: 10.3389/fsurg.2019.00076] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background: There is a long history, beginning in the 1940s, of ablative neurosurgery on the pallidal efferent fibers to treat patients suffering from Parkinson's disease (PD). Since the early 1990s, we undertook a re-actualization of the approach to the subthalamic region, and proposed, on a histological basis, to target specifically the pallidothalamic tract at the level of Forel's field H1. This intervention, the pallidothalamic tractotomy (PTT), has been performed since 2011 using the MR-guided focused ultrasound (MRgFUS) technique. A reappraisal of the histology of the pallidothalamic tract was combined recently with an optimization of our lesioning strategy using thermal dose control. Objective: This study was aimed at demonstrating the efficacy and risk profile of MRgFUS PTT against chronic therapy-resistant PD. Methods: This consecutive case series reflects our current treatment routine and was collected between 2017 and 2018. Fifty-two interventions in 47 patients were included. Fifteen patients received bilateral PTT. The median follow-up was 12 months. Results: The Unified Parkinson's Disease Rating Scale (UPDRS) off-medication postoperative score was compared to the baseline on-medication score and revealed percentage reductions of the mean of 84% for tremor, 70% for rigidity, and 73% for distal hypobradykinesia, all values given for the treated side. Axial items (for voice, trunk and gait) were not significantly improved. PTT achieved 100% suppression of on-medication dyskinesias as well as reduction in pain (p < 0.001), dystonia (p < 0.001) and REM sleep disorders (p < 0.01). Reduction of the mean L-Dopa intake was 55%. Patients reported an 88% mean tremor relief and 82% mean global symptom relief on the operated side and 69% mean global symptom improvement for the whole body. There was no significant change of cognitive functions. The small group of bilateral PTTs at 1 year follow-up shows similar results as compared to unilateral PTTs but does not allow to draw firm conclusions at this point. Conclusion: MRgFUS PTT was shown to be a safe and effective intervention for PD patients, addressing all symptoms, with varying effectiveness. We discuss the need to integrate the preoperative state of the thalamocortical network as well as the psycho-emotional dimension.
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Affiliation(s)
- Marc N Gallay
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | - David Moser
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | - Franziska Rossi
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | | | - Maja Strasser
- Neurologische Praxis Solothurn, Solothurn, Switzerland
| | - Robert Bühler
- Neurological Division, Bürgerspital Solothurn, Solothurn, Switzerland
| | | | | | | | - Christian Federau
- Department of Radiology, University Hospital Basel, Basel, Switzerland.,Institute for Biomedical Engineering, ETH Zürich, University Zürich, Zurich, Switzerland
| | - Daniel Jeanmonod
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
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Fernandez-Garcia C, Alonso-Frech F, Monje MHG, Matias-Guiu J. Role of deep brain stimulation therapy in the magnetic resonance-guided high-frequency focused ultrasound era: current situation and future prospects. Expert Rev Neurother 2019; 20:7-21. [PMID: 31623494 DOI: 10.1080/14737175.2020.1677465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Deep brain stimulation (DBS) is a well-established treatment of movement disorders; but recently there has been an increasing trend toward the ablative procedure magnetic resonance-guided focused ultrasound (MRgFU). DBS is an efficient neuromodulatory technique but associated with surgical complications. MRIgFUS is an incision-free method that allows thermal lesioning, with fewer surgical complications but irreversible effects.Areas covered: We look at current and prospective aspects of both techniques. In DBS, appropriate patient selection, improvement in surgical expertise, target accuracy (preoperative and intraoperative imaging), neurophysiological recordings, and novel segmented leads need to be considered. However, increased number of older patients with higher comorbidities and risk of DBS complications (mainly intracranial hemorrhage, but also infections, hardware complications) make them not eligible for surgery. With MRgFUS, hemorrhage risks are virtually nonexistent, infection or hardware malfunction are eliminated, while irreversible side effects can appear.Expert commentary: Comparison of the efficacy and risks associated with these techniques, in combination with a growing aged population in developed countries with higher comorbidities and a preference for less invasive treatments, necessitates a review of the indications for movement disorders and the most appropriate treatment modalities.
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Affiliation(s)
- C Fernandez-Garcia
- Department of Neurosurgery, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Madrid, Spain.,Medicine Department, Universidad Complutense, Madrid, Spain
| | - F Alonso-Frech
- Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain.,HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - M H G Monje
- HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - J Matias-Guiu
- Medicine Department, Universidad Complutense, Madrid, Spain.,Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain
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Prajakta G, Horisawa S, Kawamata T, Taira T. Feasibility of Staged Bilateral Radiofrequency Ventral Intermediate Nucleus Thalamotomy for Bilateral Essential Tremor. World Neurosurg 2019; 125:e992-e997. [DOI: 10.1016/j.wneu.2019.01.224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 11/24/2022]
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Guridi J, Rodriguez-Rojas R, Carmona-Abellán M, Parras O, Becerra V, Lanciego JL. History and future challenges of the subthalamic nucleus as surgical target: Review article. Mov Disord 2018; 33:1540-1550. [DOI: 10.1002/mds.92] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 01/22/2023] Open
Affiliation(s)
- Jorge Guridi
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Rafael Rodriguez-Rojas
- Centro Integral de Neurociencias; University Hospital HM Puerta del Sur; Móstoles Madrid Spain
| | - Mar Carmona-Abellán
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Olga Parras
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Victoria Becerra
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Jose Luis Lanciego
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas; Pamplona Spain
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Schreglmann SR, Krauss JK, Chang JW, Martin E, Werner B, Bauer R, Hägele-Link S, Bhatia KP, Kägi G. Functional lesional neurosurgery for tremor: back to the future? J Neurol Neurosurg Psychiatry 2018; 89:727-735. [PMID: 29269505 DOI: 10.1136/jnnp-2017-316301] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/18/2017] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
For nearly a century, functional neurosurgery has been applied in the treatment of tremor. While deep brain stimulation has been in the focus of academic interest in recent years, the establishment of incisionless technology, such as MRI-guided high-intensity focused ultrasound, has again stirred interest in lesional approaches.In this article, we will discuss the historical development of surgical technique and targets, as well as the technological state-of-the-art of conventional and incisionless interventions for tremor due to Parkinson's disease, essential and dystonic tremor and tremor related to multiple sclerosis (MS) and midbrain lesions. We will also summarise technique-inherent advantages of each technology and compare their lesion characteristics. From this, we identify gaps in the current literature and derive future directions for functional lesional neurosurgery, in particularly potential trial designs, alternative targets and the unsolved problem of bilateral lesional treatment. The results of a systematic review and meta-analysis of the consistency, efficacy and side effect rate of lesional treatments for tremor are presented separately alongside this article.
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Affiliation(s)
- Sebastian R Schreglmann
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, London, UK
| | - Joachim K Krauss
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ernst Martin
- Center for Focused Ultrasound, University of Zurich, Children's Hospital Zurich, Zurich, Switzerland
| | - Beat Werner
- Center for Focused Ultrasound, University of Zurich, Children's Hospital Zurich, Zurich, Switzerland
| | - Ronald Bauer
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Stefan Hägele-Link
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, London, UK
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Gallay MN, Moser D, Jeanmonod D. Safety and accuracy of incisionless transcranial MR-guided focused ultrasound functional neurosurgery: single-center experience with 253 targets in 180 treatments. J Neurosurg 2018:1-10. [PMID: 29799340 DOI: 10.3171/2017.12.jns172054] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/11/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVESince the first clinical application of the incisionless magnetic resonance-guided focused ultrasound (MRgFUS) technology only small series of patients have been reported, and thus only extrapolations of the procedure-related risks could be offered. In this study, the authors analyze side-effects and targeting accuracy in 180 consecutive treatments with MRgFUS for chronic therapy-resistant idiopathic Parkinson's disease (PD), essential tremor (ET), cerebellar tremor (CT), and neuropathic pain (NP), all performed in their dedicated center.METHODSA total of 180 treatments with MRgFUS for chronic therapy-resistant idiopathic PD, ET, CT, and NP were prospectively assessed for side-effects and targeting accuracy. Monitoring for later side-effects was continued for at least 3 months after the procedure in all but 1 case (0.6%); in that single case, the patient was lost to follow-up after an uneventful early postoperative course. The surgical targets were the pallidothalamic tract (pallidothalamic tractotomy, n = 105), the cerebellothalamic tract (cerebellothalamic tractotomy, n = 50), the central lateral nucleus (central lateral thalamotomy, n = 84), the centrum medianum (centrum medianum thalamotomy, n = 12), and the globus pallidus (pallidotomy, n = 2). Cognitive testing was performed before, 1-2 days after, and 1 year after the procedure. The Mini-Mental State Examination (MMSE) was used for the first 29 cases and was then replaced by the Montreal Cognitive Assessment (MoCA). Lesion reconstruction and measurement of targeting accuracy were done on 2-day posttreatment MR images for each performed target. To determine targeting accuracy measurement, 234 out of the 253 lesions depicted in the 2-day postoperative MR examination could be 3D-reconstructed.RESULTSThe mean MoCA score was slightly improved 2 days postoperatively (p = 0.002) and remained stable at 1-year follow-up (p = 0.03). The mean MMSE score was also slightly improved 2 days postoperatively and at 1-year follow-up, but the improvement was not statistically significant (p = 0.06 and p = 0.2, respectively). The mean (± SD) accuracy was 0.32 ± 0.29 mm, 0.29 ± 0.28 mm, and 0.44 ± 0.39 mm for the mediolateral, anteroposterior, and dorsoventral dimensions, respectively. The mean 3D accuracy was 0.73 ± 0.39 mm. As to side-effects, 14 events over 180 treatments were documented. They were classified into procedure-related (n = 4, 2.2%), effect on neighboring structures (n = 3, 1.7%), and disease-related (n = 7, 3.9%). There was no bleeding.CONCLUSIONSThe incisionless transcranial MRgFUS technology demonstrates a higher targeting accuracy and a lower side-effect profile than techniques requiring cerebral penetration. In the absence of penetration brain shift, this technique avoids the placement of a thermolesion away from the chosen target, thus suppressing the need for reversible therapeutic energy application. With the use of proper physiopathology-based targets, definitive therapeutic effects can be coupled with sparing of sensory, motor, and paralimbic/multimodal thalamocortical functions. Clinical efficacy, not analyzed in this investigation, will ultimately rest in proper target selection and optimized thermolesional coverage of the target.
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Revisiting bilateral thalamotomy for tremor. Clin Neurol Neurosurg 2017; 158:103-107. [PMID: 28505539 DOI: 10.1016/j.clineuro.2017.04.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 03/28/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Abstract
MRI guided focused ultrasound surgery (MRgFUS) has been FDA approved for unilateral treatment of essential tremor (ET). Before this non-incisional lesioning method can be applied to the treatment of both hemispheres the previous experience with bilateral thalamic ablation must be addressed. In particular, the high incidence of worsening of speech and balance associated with bilateral surgical thalamotomy, a rationale for the development of deep brain stimulation. The highest incidence of these complication occurred in the early years of surgery for movement disorders, when neither MRI nor current stereotactic methods were available. The vast majority of these initial patients suffering these complications had Parkinson's disease where approximately 30% developed worsening dysarthria and ataxia after bilateral thalamotomy. Patients suffering these complications commonly had baseline abnormalities in speech and balance or worsening symptoms after a first unilateral procedure. The more contemporary experience with bilateral thalamotomy in the ET population is both much more limited in patient numbers (includes patients after Gamma Knife radiosurgery), and shows a much lower rate of these complications (approximately 5%). This more recent experience suggests that bilateral thalamotomy using closed incisionless methods such as MRgFUS has the potential to safely improve ET patients with axial or bilateral limb involvement, if done in a staged manner excluding patients with baseline dysarthria or ataxia or transient worsening of these symptoms following a unilateral procedure.
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12
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Abstract
Surgical therapy for Parkinson's disease (PD) has been a treatment option for over 100 years. Advances in the knowledge of basal ganglia physiology and in techniques of stereotactic neurosurgery and neuroimaging have allowed more accurate placement of lesions or "brain pacemakers" in the sensorimotor regions of target nuclei. This, in turn, has led to improved efficacy with fewer complications than in the past. Currently, bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) or the internal segment of the globus pallidus (GPi) is the preferred option (and is approved by the US Food and Drug Administration) for the surgical treatment of PD. The most important predictors for outcome for DBS for PD are patient selection and electrode location. Patients should have a documented preoperative improvement from dopaminergic medication of at least 30% in the patient's Unified Parkinson's Disease Rating Scale motor disability scores. A levodopa challenge may be needed to document the best "on" state. Dementia or active cognitive decline must be excluded. Active psychiatric disease should be treated preoperatively. Patients should be motivated, with good support systems, and committed to the postoperative management of DBS therapy. Deep brain stimulation should be considered when the patient begins to experience dyskinesia and on-off fluctuations despite optimal medical therapy. Deep brain stimulation is not a good option at the final stages of the disease because of the increased incidence of dementia and severe comorbidity. The DBS electrode should be placed in the sensorimotor region of the GPi or STN. Subthalamic nucleus and GPi DBS can improve all motor aspects of PD, as well as predictable "on" time, without dyskinesia or fluctuations. On average, STN DBS results in a greater reduction of dopaminergic medication compared with GPi DBS. Because of the smaller size of the target region, the pulse generator battery life is longer with STN then with GPi DBS. Deep brain stimulation programming is a skill that is readily learned and may be required of all neurologists in the future. Emerging surgical therapies are restorative, and they aim to replace or regenerate degenerating dopaminergic neurons. These include embryonic mesencephalic tissue transplantation, human embryonic stem cell transplantation, and gene-derived methods of intracerebral implantation of growth factors and dopamine- producing cell lines. It will be important to determine whether DBS, if performed before the onset of motor response complications to medical therapy, may prevent this stage of disease altogether or delay it for a significant period of time. The same question applies to the future with restorative therapy.
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Affiliation(s)
- Helen Bronte-Stewart
- Department of Neurology, Stanford University Medical Center, 300 Pasteur Drive, Room A-343, Stanford, CA 94305-5235, USA.
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Higuchi Y, Iacono RP. Surgical complications in patients with Parkinson's disease after posteroventral pallidotomy. Neurosurgery 2003; 52:558-71; discussion 568-71. [PMID: 12590680 DOI: 10.1227/01.neu.0000047817.60776.5c] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2001] [Accepted: 10/18/2002] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the potential operative morbidity in posteroventral pallidotomy (PVP) for patients with Parkinson's disease. METHODS We designed a retrospective study that included 796 consecutive patients (mean age, 64.9 yr; male, 559; female, 237) with Parkinson's disease. All PVPs (simultaneous bilateral PVP, n = 272; sequential bilateral PVP, n = 88; unilateral PVP, n = 436) were performed during a 7-year period. The total number of operations was 884, and the number of PVP procedures was 1156. In 108 patients, ventral intermediate nucleus thalamotomy was performed simultaneously. RESULTS The overall complication rate, including temporary problems, was 15.3% of 884 operations. Permanent complications occurred in 3.6% of total operations. Intracranial hemorrhage occurred in 24 operations (2.7%). In seven of them, the patients required craniotomy and hematoma evacuation and sustained a disabling motor deficit (0.8%). Intracranial hemorrhage occurred more often in patients who underwent microelectrode recording and had a history of chronic hypertension. Hemiparesis without intracranial hematoma occurred in 12 operations (1.4%). Microelectrode recording was a risk factor for postoperative hemiparesis without hemorrhage. In 19 operations (2.1%), patients developed a partial visual field deficit. Speech disturbance after surgery was observed in 23 operations (2.6%) but resolved in 17 by 1 week after surgery. In 55 operations (6.2%), patients developed postoperative confusion. This occurred more often in elderly patients and those with advanced disease. In 17 operations (1.9%), patients required observation in the intensive care unit because of postoperative hypotension. CONCLUSION Complications from stereotactic pallidotomy were not frequent. However, the residual symptoms from complications can be serious in many cases.
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Affiliation(s)
- Yoshinori Higuchi
- Division of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, USA
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Guridi J, Obeso JA. The subthalamic nucleus, hemiballismus and Parkinson's disease: reappraisal of a neurosurgical dogma. Brain 2001; 124:5-19. [PMID: 11133783 DOI: 10.1093/brain/124.1.5] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The subthalamic nucleus (STN) currently is considered to play a key role in the pathophysiological origin of the parkinsonian state and is therefore the main target for surgical treatment of Parkinson's disease. The authors review the incidence of hemichorea/ballism (HCB) as a complication of thalamotomy, pallidotomy or campotomy procedures before the introduction of levodopa therapy, including the few reported cases accompanied by a neuropathological study. The literature shows that only a small number of parkinsonian patients with HCB had a lesion of the STN. Preliminary data in Parkinson's disease patients submitted to a subthalamotomy with current functional stereotaxy also indicate that HCB is a very rare complication. To explain this observation, we suggest that the parkinsonian state is characterized by an increased threshold for the induction of dyskinesia following STN lesioning. This arises as a consequence of reduced activity in the 'direct' GABA projection to the globus pallidus medialis (GPm) which accompanies dopamine depletion. Lesioning of the STN reduces excitation of the GPm, and theoretically this should induce dyskinesias. However, an STN lesion also, simultaneously, further reduces the hypoactivity in the globus pallidus lateralis (GPl) that is a feature of Parkinson's disease, and hence may compensate for GPm hypoactivity, thus self-stabilizing basal ganglia output activity and reducing the risk of HCB. We conclude that lesioning of the STN in Parkinson's disease is a feasible approach in some circumstances.
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Affiliation(s)
- J Guridi
- Service of Neurosurgery, Hospital de Navarra, 31008 Pamplona, Spain
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Ghika J, Ghika-Schmid F, Fankhauser H, Assal G, Vingerhoets F, Albanese A, Bogousslavsky J, Favre J. Bilateral contemporaneous posteroventral pallidotomy for the treatment of Parkinson's disease: neuropsychological and neurological side effects. Report of four cases and review of the literature. J Neurosurg 1999; 91:313-21. [PMID: 10433321 DOI: 10.3171/jns.1999.91.2.0313] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report the underestimated cognitive, mood, and behavioral complications in patients who have undergone bilateral contemporaneous pallidotomy, as seen in their early experience with functional neurosurgery for Parkinson's disease (PD) that is accompanied by severe motor fluctuations before pallidal stimulation. Four patients, not suffering from dementia, with advanced (Hoehn and Yahr Stages III-IV), medically untreatable PD featuring severe "on-off" fluctuations underwent bilateral contemporaneous posteroventral pallidotomy (PVP). All patients were evaluated according to the Core Assessment Program for Intracerebral Transplantations (CAPIT) protocol without positron emission tomography scans but with additional neuropsychological cognitive, mood, and behavior testing. For the first 3 to 6 months postoperatively, all patients showed a mean improvement of motor scores on the Unified Parkinson's Disease Rating Scale (UPDRS), in the best "on" (21%) and worst "off" (40%) UPDRS III motor subscale, a mean 30% improvement in the UPDRS II activities of daily living (ADL) subscore, and 60% on the UPDRS IV complications of treatment subscale. Dyskinesia disappeared almost completely, and the mean daily duration of the off time was reduced by an average of 60%. Despite these good results in the CAPIT scores, one patient experienced a partially regressive corticobulbar syndrome with dysphagia, dysarthria, and increased drooling. No emotional lability was found in this patient, but he did demonstrate severe bilateral postoperative pretarsal blepharospasm (apraxia of eyelid opening), which interfered with walking and which required treatment with high-dose subcutaneous injections of botulinum toxin. No patient showed visual field defects or hemiparesis, but postoperative depression, changes in personality, behavior, and executive functions were seen in two individuals. Postoperative abulia was reported by the family of one patient, who lost his preoperative aggressiveness and drive in terms of ADL, speech, business, family life, and hobbies, and became more sleepy and fatigued. One patient reported postoperative mental automatisms, such as compulsive mental counting, and circular thoughts and reasoning during off phases; postoperative depression was found in two patients. However, none of the patients demonstrated these symptoms during intraoperative microelectrode stimulation. These findings are compatible with previous reports on bilateral pallidal lesions. A progressive lowering of UPDRS subscores was seen after 12 months, consistent with the progression of the disease. Bilateral simultaneous pallidotomy may be followed by emotional, behavioral, and cognitive deficits such as depression, obsessive-compulsive disorders, and loss of psychic autoactivation-abulia, as well as disabling corticobulbar dysfunction and apraxia of eyelid opening, in addition to previously described motor and visual field deficits, which make this surgery undesirable even though significant improvement in motor deficits can be achieved.
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Affiliation(s)
- J Ghika
- Division Autonome de Neuropsychologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Posteroventral pallidotomy: its effect on motor symptoms and scores of MMPI test in patients with Parkinson's disease. Parkinsonism Relat Disord 1997; 3:7-20. [DOI: 10.1016/s1353-8020(96)00031-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/1996] [Indexed: 11/29/2022]
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Laplane D, Baulac M, Widlöcher D, Dubois B. Pure psychic akinesia with bilateral lesions of basal ganglia. J Neurol Neurosurg Psychiatry 1984; 47:377-85. [PMID: 6726263 PMCID: PMC1027779 DOI: 10.1136/jnnp.47.4.377] [Citation(s) in RCA: 123] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Three patients showed dramatic psychic akinesia after recovery from toxic encephalopathy. They had no or only mild motor disorders. The spontaneous psychic akinesia was reversible when the patient was stimulated, as if there was a loss of self psychic activation. Intellectual capacities were normal. Two patients had stereotyped behaviours resembling compulsions. In all patients CT cans showed bilateral lesions in the basal ganglia, mainly within the globus pallidus.
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Abstract
Study of the speech disorders of Parkinsonism provides a paradigm of the integration of phonation, articulation and language in the production of speech. The initial defect in the untreated patient is a failure to control respiration for the purpose of speech and there follows a forward progression of articulatory symptoms involving larynx, pharynx, tongue and finally lips. There is evidence that the integration of speech production is organised asymmetrically at thalamic level. Experimental or therapeutic lesions in the region of the inferior medial portion of ventro-lateral thalamus may influence the initiation, respiratory control, rate and prosody of speech. Higher language functions may also be involved in thalamic integration: different forms of anomia are reported with pulvinar and ventrolateral thalamic lesions and transient aphasia may follow stereotaxis. The results of treatment with levodopa indicates that neurotransmitter substances enhance the clarity, volume and persistence of phonation and the latency and smoothness of articulation. The improvement of speech performance is not necessarily in phase with locomotor changes. The dose-related dyskinetic effects of levodopa, which appear to have a physiological basis in observations previously made in post-encephalitic Parkinsonism, not only influence the prosody of speech with near-mutism, hesitancy and dysfluency but may affect work-finding ability and in instances of excitement (erethism) even involve the association of long-term memory with speech. In future, neurologists will need to examine more closely the role of neurotransmitters in speech production and formulation.
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Mosso JA, Rand RW. Management of parkinson's disease--combined therapy with levodopa and thalamotomy. West J Med 1975; 122:1-6. [PMID: 1109524 PMCID: PMC1130254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
An increasing number of parkinsonian patients in whom levodopa fails to relieve tremor are being referred for thalamotomy. The literature suggests that in as many as 50 percent of patients treated with levodopa, there is no relief of tremor because of refractoriness to the medication or intractable side effects which limit dosage. Thalamotomy abolishes contralateral tremor in 90 percent of patients, with an associated mortality rate of 1 to 2 percent and morbidity of 6 percent. The relative merits and complications of levodopa and thalamotomy were reviewed and a therapeutic regimen designed in which the two approaches to treatment are combined to most effectively deal with all the symptoms of parkinsonism.
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Christensen AL, Juul-Jensen P, Malmros R, Harmsen A. Psychological evaluation of intelligence and personality in parkinsonism before and after stereotaxic surgery. Acta Neurol Scand 1970; 46:527-37. [PMID: 4926785 DOI: 10.1111/j.1600-0404.1970.tb05810.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
The beneficial clinical effects of stereotactic lesions in the ventrolateral nucleus of the thalamus in the treatment of Parkinsonism are well established. Studies of the cognitive and personality changes, however, have given contradictory results. This may be due to the great variety of tests used, to lack of control groups and to the fact that some investigators have studied only unilateral operations, whereas others have included some patients operated on bilaterally. Changes, presumably permanent, have been reported in intelligence (Jurko and Andy, 1961; Lenshoek and Manem, 1960; Niehbuhr, 1962; Jurko and Andy, 1964); concept formation (Jurko and Andy, 1961); extraversion (Fortin, 1960; Jurko and Andy, 1961); and anxiety (Niehbuhr, 1962). Transient changes have been reported in intelligence (Riklan, 1961; Levita et al., 1964); human figure drawing (Riklan et al., 1962); integrity of personality (Fortin et al., 1961; Fortin, 1960; Riklan, 1961); and somatosensory status (Proctor et al., 1963). In other studies no change was found following the operation (Bravo and Cooper, 1959; Gillingham et al., 1960; Gillingham et al., 1964; Levita and Riklan, 1965; Muller and Yasargil, 1959; Riklan, 1962).
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Jenkins AC. Speech defects following stereotaxic operations for the relief of tremor and rigidity in parkinsonism. Med J Aust 1968; 1:585-8. [PMID: 4869708 DOI: 10.5694/j.1326-5377.1968.tb28716.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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HUGHES B. INVOLUNTARY MOVEMENTS FOLLOWING STEREOTACTIC OPERATIONS FOR PARKINSONISM WITH SPECIAL REFERENCE TO HEMI-CHOREA (BALLISMUS). J Neurol Neurosurg Psychiatry 1965; 28:291-303. [PMID: 14338118 PMCID: PMC495908 DOI: 10.1136/jnnp.28.4.291] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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