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Zong R, Li X, Yin C, He J, Zhang D, Bian X, Huang L, Zhou J, Ling Z, Ma L, Lou X, Pan L, Yu X. Magnetic resonance-guided focused ultrasound for essential tremor: a prospective, single center, single-arm study. Neural Regen Res 2024; 19:2075-2080. [PMID: 38227538 DOI: 10.4103/1673-5374.391192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 11/04/2023] [Indexed: 01/17/2024] Open
Abstract
JOURNAL/nrgr/04.03/01300535-202409000-00041/figure1/v/2024-01-16T170235Z/r/image-tiff The safety and effectiveness of magnetic resonance-guided focused ultrasound thalamotomy has been broadly established and validated for the treatment of essential tremor. In 2018, the first magnetic resonance-guided focused ultrasound system in Chinese mainland was installed at the First Medical Center of the PLA General Hospital. This prospective, single center, open-label, single-arm study was part of a worldwide prospective multicenter clinical trial (ClinicalTrials.gov Identifier: NCT03253991) conducted to confirm the safety and efficacy of magnetic resonance-guided focused ultrasound for treating essential tremor in the local population. From 2019 to 2020, 10 patients with medication refractory essential tremor were recruited into this open-label, single arm study. The treatment efficacy was determined using the Clinical Rating Scale for Tremor. Safety was evaluated according to the incidence and severity of adverse events. All of the subjects underwent a unilateral thalamotomy targeting the ventral intermediate nucleus. At the baseline assessment, the estimated marginal mean of the Clinical Rating Scale for Tremor total score was 58.3 ± 3.6, and this improved after treatment to 23.1 ± 6.4 at a 12-month follow-up assessment. A total of 50 adverse events were recorded, and 2 were defined as serious. The most common intraoperative adverse events were nausea and headache. The most frequent postoperative adverse events were paresthesia and equilibrium disorder. Most of the adverse events were mild and usually disappeared within a few days. Our findings suggest that magnetic resonance-guided focused ultrasound for the treatment of essential tremor is effective, with a good safety profile, for patients in Chinese mainland.
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Affiliation(s)
- Rui Zong
- Seniro Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Xuemei Li
- Clinics of Cadre, Department of Outpatient, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Chunyu Yin
- Clinics of Cadre, Department of Outpatient, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Jianfeng He
- Department of Radiology, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Dekang Zhang
- Department of Radiology, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Xiangbing Bian
- Department of Radiology, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Lichao Huang
- Seniro Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Jiayou Zhou
- Seniro Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Zhipei Ling
- Seniro Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Lin Ma
- Department of Radiology, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Xin Lou
- Department of Radiology, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Longsheng Pan
- Seniro Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Xinguang Yu
- Seniro Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
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Gironell A, Marín-Lahoz J, Póveda S. Essential Tremor: Update of Therapeutic Strategies. Med Clin (Barc) 2024; 162:599-605. [PMID: 38553256 DOI: 10.1016/j.medcli.2023.12.013] [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: 10/31/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 06/18/2024]
Abstract
In the last decades there has been progress in the treatment of essential tremor (TE) especially in the surgical field and to a lesser extent in the pharmacological field. We carry out a review of the currently available treatments. The first intervention is the use of non-pharmacological and non-surgical strategies (general advice, occupational therapy, speech therapy, psychotherapy). With discrete advances, the pharmacological treatment is not very satisfactory. Only 30-60% of patients have a positive response, and in these the anti-tremor effectiveness is 40-60%. The first-line drugs are still propranolol and primidone. In cases with severe tremor we will consider a surgical option, the method of choice being thalamotomy using high-intensity focused ultrasound. In the future we must continue to study the pathophysiology of TE, develop drugs specifically designed for TE and improve the technology of available invasive techniques.
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Affiliation(s)
- Alexandre Gironell
- Unidad de Trastornos del Movimiento, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | - Juan Marín-Lahoz
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Grupo de Neurociencias, IIS Aragón, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
| | - Santiago Póveda
- Unidad de Trastornos del Movimiento, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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Lefaucheur JP, Moro E, Shirota Y, Ugawa Y, Grippe T, Chen R, Benninger DH, Jabbari B, Attaripour S, Hallett M, Paulus W. Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter. Clin Neurophysiol 2024; 164:57-99. [PMID: 38852434 DOI: 10.1016/j.clinph.2024.05.007] [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: 10/17/2023] [Revised: 03/02/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Clinical Neurophysiology Unit, Henri Mondor University Hospital, AP-HP, Créteil, France; EA 4391, ENT Team, Paris-Est Créteil University, Créteil, France.
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, CHU of Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Yuichiro Shirota
- Department of Neurology, Division of Neuroscience, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikazu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Talyta Grippe
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Neuroscience Graduate Program, Federal University of Minas Gerais, Belo Horizonte, Brazil; Krembil Brain Institute, Toronto, Ontario, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada
| | - David H Benninger
- Service of Neurology, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Walter Paulus
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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Tamburin S, Paio F, Bovi T, Bulgarelli G, Longhi M, Foroni R, Mantovani E, Polloniato PM, Tagliamonte M, Zivelonghi E, Zucchella C, Cavedon C, Nicolato A, Petralia B, Sala F, Bonetti B, Tinazzi M, Montemezzi S, Ricciardi GK. Magnetic resonance-guided focused ultrasound unilateral thalamotomy for medically refractory essential tremor: 3-year follow-up data. Front Neurol 2024; 15:1360035. [PMID: 38737350 PMCID: PMC11082386 DOI: 10.3389/fneur.2024.1360035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy of the ventralis intermediate (Vim) nucleus is an "incisionless" treatment for medically refractory essential tremor (ET). We present data on 49 consecutive cases of MRgFUS Vim thalamotomy followed-up for 3 years and review the literature on studies with longer follow-up data. Methods A retrospective chart review of patients who underwent MRgFUS thalamotomy (January 2018-December 2020) at our institution was performed. Clinical Rating Scale for Tremor (CRST) and Quality of Life in Essential Tremor (QUEST) scores were obtained pre-operatively and at each follow-up with an assessment of side effects. Patients had post-operative magnetic resonance imaging within 24 h and at 1 month to figure out lesion location, size, and extent. The results of studies with follow-up ≥3 years were summarized through a literature review. Results The CRST total (baseline: 58.6 ± 17.1, 3-year: 40.8 ± 18.0) and subscale scores (A + B, baseline: 23.5 ± 6.3, 3-year: 12.8 ± 7.9; C, baseline: 12.7 ± 4.3, 3-year: 5.8 ± 3.9) and the QUEST score (baseline: 38.0 ± 14.8, 3-year: 18.7 ± 13.3) showed significant improvement that was stable during the 3-year follow-up. Three patients reported tremor recurrence and two were satisfactorily retreated. Side effects were reported by 44% of patients (severe: 4%, mild and transient: 40%). The improvement in tremor and quality of life in our cohort was consistent with the literature. Conclusion We confirmed the effectiveness and safety of MRgFUS Vim thalamotomy in medically refractory ET up to 3 years.
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Affiliation(s)
- Stefano Tamburin
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Section, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Fabio Paio
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Section, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Tommaso Bovi
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giorgia Bulgarelli
- Stereotactic Neurosurgery and Radiosurgery Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Michele Longhi
- Stereotactic Neurosurgery and Radiosurgery Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Roberto Foroni
- Stereotactic Neurosurgery and Radiosurgery Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Medical Physics Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Elisa Mantovani
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Section, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Maria Polloniato
- Medical Physics Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Micaela Tagliamonte
- Neuroradiology Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Emanuele Zivelonghi
- Medical Physics Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Chiara Zucchella
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Carlo Cavedon
- Medical Physics Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Antonio Nicolato
- Stereotactic Neurosurgery and Radiosurgery Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Benedetto Petralia
- Neuroradiology Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Sala
- Neurosurgery Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurosurgery Section, Department of Neurosciences, Biomedicine, and Movement Science, University of Verona, Verona, Italy
| | - Bruno Bonetti
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Michele Tinazzi
- Neurology Unit, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Section, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Stefania Montemezzi
- Radiology Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giuseppe Kenneth Ricciardi
- Neuroradiology Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Mueller JM, Chiu LT, Lynn F, Lewis RG, Patel S, Wodziak M, Patel N, Sani S. Magnetic Resonance-Guided Focused Ultrasound without Anesthesiologist Support. Stereotact Funct Neurosurg 2024; 102:169-178. [PMID: 38657586 DOI: 10.1159/000537695] [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: 12/20/2023] [Accepted: 02/02/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Magnetic resonance-guided focused ultrasound (MRgFUS) is an effective treatment option for essential tremor (ET) and tremor dominant Parkinson's disease (TDPD), which is often performed with sedation or in the presence of an anesthesiologist in an effort to minimize adverse events and maximize patient comfort. This study explores the safety, feasibility, and tolerability of performing MRgFUS without an anesthesiologist. METHODS This is a single academic center, retrospective review of 180 ET and TDPD patients who underwent MRgFUS treatment without anesthesiologist support. Patient demographics, intra-procedural treatment parameters, peri-procedural adverse events, and 3-month Clinical Rating Scale for Tremor Part B (CRST-B) scores were compared to MRgFUS studies that utilized varying degrees of anesthesia. RESULTS There were no anesthesia related adverse events or unsuccessful treatments. There were no early treatment terminations due to patient discomfort, regardless of skull density ratio. 94.6% of patients would repeat the procedure again. The most common side effects during treatment were facial/tongue paresthesia (26.3%), followed by nausea (22.3%), dysarthria (8.6%), and scalp pain (8.0%). No anxiolytic, pain, or antihypertensive medications were administered. The most common early adverse event after MRgFUS procedure was gait imbalance (58.3%). There was a significant reduction of 83.1% (83.4% ET and 80.5% TDPD) of the mean CRST-B scores of the treated hand when comparing 3-month and baseline scores (1.8 vs. 10.9, n = 109, p < 0.0001). CONCLUSION MRgFUS without intra-procedural anesthesiologist support is a safe, feasible, and well-tolerated option, without an increase in peri-procedural adverse events.
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Affiliation(s)
- Julia M Mueller
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA,
| | - Lucinda T Chiu
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Fiona Lynn
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Rachel G Lewis
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shama Patel
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Matthew Wodziak
- Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA
| | - Neepa Patel
- 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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Amami P, Prioni S, Fusar Poli M, Pascuzzo R, Bocchi E, Golfrè Andreasi N, Devigili G, Cilia R, Rinaldo S, Levi V, Ghielmetti F, Grisoli M, Gemma M, DiMeco F, Eleopra R, Piacentini S. Pain related to MRgFUS: a merely minor transient adverse event? J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333401. [PMID: 38641369 DOI: 10.1136/jnnp-2024-333401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/29/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Paolo Amami
- Clinical Neuropsychology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Sara Prioni
- Clinical Neuropsychology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco Fusar Poli
- Clinical Neuropsychology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Riccardo Pascuzzo
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Elisa Bocchi
- Clinical Neuropsychology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Nico Golfrè Andreasi
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Grazia Devigili
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Roberto Cilia
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Sara Rinaldo
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Vincenzo Levi
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesco Ghielmetti
- Medical Physics Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marina Grisoli
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco Gemma
- Intensive Care and Neuroanesthesia Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesco DiMeco
- Department of Neurological Surgery, Fondazione IRCCS Istituto Nazionale Neurologico Carlo Besta, Milano, Italy
- Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milano, Italy
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Sylvie Piacentini
- Clinical Neuropsychology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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7
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Arcadi A, Aviles-Olmos I, Gonzalez-Quarante LH, Gorospe A, Jiménez-Huete A, de la Corte MM, Parras O, Martin-Bastida A, Riverol M, Villino R, Guridi J, Rodríguez-Oroz MC. Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)-Thalamotomy for Essential Tremor: Lesion Location and Clinical Outcomes. Mov Disord 2024. [PMID: 38616324 DOI: 10.1002/mds.29801] [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: 11/04/2023] [Revised: 03/13/2024] [Accepted: 03/18/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Factors predicting clinical outcomes after MR-guided focused ultrasound (MRgFUS)-thalamotomy in patients with essential tremor (ET) are not well known. OBJECTIVE To examine the clinical outcomes and their relationship with patients' baseline demographic and clinical features and lesion characteristics at 6-month follow-up in ET patients. METHODS A total of 127 patients were prospectively evaluated at 1 (n = 122), 3 (n = 102), and 6 months (n = 78) after MRgFUS-thalamotomy. Magnetic resonance imaging (MRI) was obtained at 6 months (n = 60). Primary outcomes included: (1) change in the Clinical Rating Scale of Tremor (CRST)-A+B score in the treated hand and (2) frequency and severity of adverse events (AEs) at 6 months. Secondary outcomes included changes in all subitems of the CRST scale in the treated hand, CRST-C, axial tremor (face, head, voice, tongue), AEs, and correlation of primary outcomes at 6 months with lesion characteristics. Statistical analysis included linear mixed, standard, and logistic regression models. RESULTS Scores for CRST-A+B, CRST-A, CRST-B in the treated hand, CRST-C, and axial tremor were improved at each evaluation (P < 0.001). Five patients had severe AEs at 1 month that became mild throughout the follow-up. Mild AEs occurred in 71%, 45%, and 34% of patients at 1, 3, and 6 months, respectively. Lesion volume was associated with the reduction in the CRST-A (P = 0.003) and its overlapping with the ventralis intermedius nucleus (Vim) nucleus with the reduction in CRST-A+B (P = 0.02) and CRST-B (P = 0.008) at 6 months. CONCLUSIONS MRgFUS-thalamotomy improves hand and axial tremor in ET patients. Transient and mild AEs are frequent. Lesion volume and location are associated with tremor reduction. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alana Arcadi
- Neurosurgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Iciar Aviles-Olmos
- Neurology Department, Clínica Universidad de Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | - Arantza Gorospe
- Neurology Department, Clínica Universidad de Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | | | - Olga Parras
- Hospital Universitario Alava, Vitoria-Gasteiz, Spain
| | | | - Mario Riverol
- Neurology Department, Clínica Universidad de Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Rafael Villino
- Neurology Department, Clínica Universidad de Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Jorge Guridi
- Neurosurgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Maria C Rodríguez-Oroz
- Neurology Department, Clínica Universidad de Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
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8
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Jameel A, Akgun S, Yousif N, Smith J, Jones B, Nandi D, Bain P, Gedroyc W. The evolution of ventral intermediate nucleus targeting in MRI-guided focused ultrasound thalamotomy for essential tremor: an international multi-center evaluation. Front Neurol 2024; 15:1345873. [PMID: 38595847 PMCID: PMC11002122 DOI: 10.3389/fneur.2024.1345873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/23/2024] [Indexed: 04/11/2024] Open
Abstract
Background The ventral intermediate nucleus (VIM) is the premiere target in magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for tremor; however, there is no consensus on the optimal coordinates for ablation. This study aims to ascertain the various international VIM targeting approaches (VIM-TA) and any evolution in practice. Methods International MRgFUS centers were invited to share VIM-TAs in 2019 and 2021. Analyses of any modification in practice and of anatomical markers and/or tractography in use were carried out. Each VIM-TA was mapped in relation to the mid-commissural point onto a 3D thalamic nucleus model created from the Schaltenbrand-Wahren atlas. Results Of the 39 centers invited, 30 participated across the study period, providing VIM-TAs from 26 centers in 2019 and 23 in 2021. The results are reported as percentages of the number of participating centers in that year. In 2019 and 2021, respectively, 96.2% (n = 25) and 95.7% (n = 22) of centers based their targeting on anatomical landmarks rather than tractography. Increased adoption of tractography in clinical practice and/or for research was noted, changing from 34.6% to 78.3%. There was a statistically significant change in VIM-TAs in the superior-inferior plane across the study period; the percentage of VIM-TAs positioned 2 mm above the intercommissural line (ICL) increased from 16.0% in 2019 to 40.9% in 2021 (WRST, p < 0.05). This position is mapped at the center of VIM on the 3D thalamic model created based on the Schaltenbrand-Wahren atlas. In contrast, the VIM-TA medial-lateral and anterior-posterior positions remained stable. In 2022, 63.3% of participating centers provided the rationale for their VIM-TAs and key demographics. The centers were more likely to target 2 mm above the ICL if they had increased experience (more than 100 treatments) and/or if they were North American. Conclusion Across the study period, FUS centers have evolved their VIM targeting superiorly to target the center of the VIM (2 mm above the ICL) and increased the adoption of tractography to aid VIM localization. This phenomenon is observed across autonomous international centers, suggesting that it is a more optimal site for FUS thalamotomy in tremors.
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Affiliation(s)
- Ayesha Jameel
- Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sena Akgun
- Sapienza University of Rome, Rome, Italy
| | - Nada Yousif
- University of Hertfordshire, Hatfield, United Kingdom
| | - Joely Smith
- Imperial College London, London, United Kingdom
| | - Brynmor Jones
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Dipankar Nandi
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Peter Bain
- Imperial College London, London, United Kingdom
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9
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Gelman K, Melott J, Thakur V, Tarabishy AR, Brandt A, Konrad P, Ranjan M, Memon AA. MR-guided focused ultrasound thalamotomy for lithium-induced tremor: a case report and literature review. Front Neurol 2024; 14:1331241. [PMID: 38362012 PMCID: PMC10867204 DOI: 10.3389/fneur.2023.1331241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/19/2023] [Indexed: 02/17/2024] Open
Abstract
Drug-induced tremor is a common side effect of lithium with an occurrence of approximately 25% of patients. Cessation of the offending drug can be difficult, and many medical treatments for drug-induced tremor are ineffective. Deep brain stimulation (DBS) has been shown in a limited number of case reports to effectively reduce drug-induced tremor, however, which remains an invasive therapeutic option. MR-guided focused ultrasound (MRgFUS) thalamotomy is an FDA-approved non-invasive treatment for essential tremor (ET). To the best of our knowledge, MRgFUS thalamotomy has never been reported to treat drug-induced tremor. Here, we present a case of a left-handed 55-year-old man with a progressive, medically refractory lithium-induced tremor of the bilateral upper extremities. The patient underwent MRgFUS thalamotomy targeting the right ventral intermediate nucleus (VIM) of the thalamus to treat the left hand. There was almost complete resolution of his left-hand tremor immediately following MRgFUS. There were no side effects. The patient continues to show excellent tremor control at 90-day follow-up and remains free from side effects. This case demonstrates MRgFUS thalamotomy as a possible novel treatment option to treat drug-induced tremor.
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Affiliation(s)
- Kate Gelman
- School of Medicine, West Virginia University, Morgantown, WV, United States
| | - Joseph Melott
- School of Medicine, West Virginia University, Morgantown, WV, United States
| | - Vishal Thakur
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - Abdul R. Tarabishy
- School of Medicine, West Virginia University, Morgantown, WV, United States
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - Ana Brandt
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - Peter Konrad
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - Manish Ranjan
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - Adeel A. Memon
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
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10
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El-Adawy AFI, Reda MABMG, Ahmed AM, Rashad MH, Zaki MA, Mohamed MET, Hassan MAS, Abdulsalam MF, Hassan AM, Mohamed AF, Fayed AGI, Meshref M, Mansour FM, Sarhan AE, Elsheshiny AH, Abed E. Efficacy of Cerebellar Transcranial Magnetic Stimulation in Treating Essential Tremor: A Randomized, Sham-Controlled Trial. J Clin Neurol 2024; 20. [DOI: https:/doi.org/10.3988/jcn.2023.0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/09/2023] [Accepted: 11/22/2023] [Indexed: 05/31/2024] Open
Affiliation(s)
| | | | - Ali Mahmoud Ahmed
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Department of Neurology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Mohamed Ahmed Zaki
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | | | | | - Abdelmonem M Hassan
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Fathy Mohamed
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Mostafa Meshref
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Ahmed E. Sarhan
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Elsayed Abed
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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11
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Chua MMJ, Blitz SE, Ng PR, Segar DJ, McDannold NJ, White PJ, Christie S, Hayes MT, Rolston JD, Cosgrove GR. Focused Ultrasound Thalamotomy for Tremor in Parkinson's Disease: Outcomes in a Large, Prospective Cohort. Mov Disord 2023; 38:1962-1967. [PMID: 37539721 DOI: 10.1002/mds.29569] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Magnetic resonance guided focused ultrasound (MRgFUS) is United States Food and Drug Administration approved for the treatment of tremor-dominant Parkinson's disease (TdPD), but only limited studies have been described in practice. OBJECTIVES To report the largest prospective experience of unilateral MRgFUS thalamotomy for the treatment of medically refractory TdPD. METHODS Clinical outcomes of 48 patients with medically refractory TdPD who underwent MRgFUS thalamotomy were evaluated. Tremor outcomes were assessed using the Fahn-Tolosa-Marin scale and adverse effects were categorized using a structured questionnaire and clinical exam at 1 month (n = 44), 3 months (n = 34), 1 year (n = 22), 2 years (n = 5), and 3 years (n = 2). Patients underwent magnetic resonance imaging <24 hours post-procedure. RESULTS Significant tremor control persisted at all follow-ups (P < 0.001). All side effects were mild. At 3 months, these included gait imbalance (38.24%), sensory deficits (26.47%), motor weakness (17.65%), dysgeusia (5.88%), and dysarthria (5.88%), with some persisting at 1 year. CONCLUSIONS MRgFUS thalamotomy is an effective treatment for sustained tremor control in patients with TdPD. © 2023 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Melissa M J Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah E Blitz
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick R Ng
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David J Segar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathan J McDannold
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - P Jason White
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah Christie
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T Hayes
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Kindler C, Upadhyay N, Purrer V, Schmeel FC, Borger V, Scheef L, Wüllner U, Boecker H. MRgFUS of the nucleus ventralis intermedius in essential tremor modulates functional connectivity within the classical tremor network and beyond. Parkinsonism Relat Disord 2023; 115:105845. [PMID: 37717502 DOI: 10.1016/j.parkreldis.2023.105845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/24/2023] [Accepted: 09/02/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) of the thalamic ventral intermediate nucleus is an incisionless lesional treatment for essential tremor. OBJECTIVE To examine relationships between tremor severity and functional connectivity in patients with essential tremor and to assess long-term changes in the tremor network after sonication of the ventral intermediate nucleus. METHODS Twenty-one patients with essential tremor (70.33 ± 11.32 years) were included in the final analysis and underwent resting state functional magnetic resonance imaging at 3 T before and 6 months after treatment. Tremor severity (Fahn-Tolosa-Marin Clinical Rating Scale) was evaluated and functional connectivity was investigated using independent component analysis. RESULTS MRgFUS of the thalamic ventral intermediate nucleus reduced contralateral tremor effectively. Multiple regression analysis revealed exclusively negative correlations between FC and tremor severity, notably in the right cerebellar lobe VI and the left cerebellar lobe VIIIa (cerebellar network), in the left occipital fusiform gyrus (lateral visual network), the anterior division of the left superior temporal gyrus (fronto-parieto-temporal network), and in the posterior division of the left parahippocampal gyrus and the bilateral lingual gyri (default mode network). Six months after treatment, increased functional connectivity was observed in almost all tremor-associated clusters, except the cluster localized in the left cerebellum. CONCLUSIONS Our findings suggest that tremor-related activity in essential tremor extends beyond the classical cerebellar network, additionally involving areas related to visual processing. Functional restoration of network activity after sonication of the ventral intermediate nucleus is observed within the classical tremor network (cerebellum) and notably also in visual processing areas.
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Affiliation(s)
- Christine Kindler
- Department of Neurology, University Hospital Bonn, Bonn, Germany; German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | - Neeraj Upadhyay
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany; Division 'Clinical Functional Imaging', Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Veronika Purrer
- Department of Neurology, University Hospital Bonn, Bonn, Germany; German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | | | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Lukas Scheef
- Division 'Clinical Functional Imaging', Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Ullrich Wüllner
- Department of Neurology, University Hospital Bonn, Bonn, Germany; German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Henning Boecker
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany; Division 'Clinical Functional Imaging', Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
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13
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Lu H, Wang X, Lou X. Current applications for magnetic resonance-guided focused ultrasound in the treatment of Parkinson's disease. Chin Med J (Engl) 2023; 136:780-787. [PMID: 36914938 PMCID: PMC10150909 DOI: 10.1097/cm9.0000000000002319] [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: 12/22/2022] [Indexed: 03/16/2023] Open
Abstract
ABSTRACT Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel and minimally invasive technology. Since the US Food and Drug Administration approved unilateral ventral intermediate nucleus-MRgFUS for medication-refractory essential tremor in 2016, studies on new indications, such as Parkinson's disease (PD), psychiatric diseases, and brain tumors, have been on the rise, and MRgFUS has become a promising method to treat such neurological diseases. Currently, as the second most common degenerative disease, PD is a research hotspot in the field of MRgFUS. The actions of MRgFUS on the brain range from thermoablation, blood-brain barrier (BBB) opening, to neuromodulation. Intensity is a key determinant of ultrasound actions. Generally, high intensity can be used to precisely thermoablate brain targets, whereas low intensity can be used as molecular therapies to modulate neuronal activity and open the BBB in conjunction with injected microbubbles. Here, we aimed to summarize advances in the application of MRgFUS for the treatment of PD, with a focus on thermal ablation, BBB opening, and neuromodulation, in the hope of informing clinicians of current applications.
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Affiliation(s)
- Haoxuan Lu
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing 100853, China
| | - Xiaoyu Wang
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing 100853, China
- School of Medicine, Nankai University, Tianjin 300071, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing 100853, China
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14
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Yamamoto K, Sarica C, Loh A, Vetkas A, Samuel N, Milano V, Zemmar A, Germann J, Cheyuo C, Boutet A, Elias GJ, Ito H, Taira T, Lozano AM. Magnetic resonance-guided focused ultrasound for the treatment of tremor. Expert Rev Neurother 2022; 22:849-861. [PMID: 36469578 DOI: 10.1080/14737175.2022.2147826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Magnetic resonance-guided focused ultrasound (MRgFUS) is an emerging treatment for tremor and other movement disorders. An incisionless therapy, it is becoming increasingly common worldwide. However, given MRgFUS' relative novelty, there remain limited data on its benefits and adverse effects. AREAS COVERED We review the current state of evidence of MRgFUS for tremor, highlight its challenges, and discuss future perspectives. EXPERT OPINION Essential tremor (ET) has been the major indication for MRgFUS since a milestone randomized controlled trial (RCT) in 2016, with substantial evidence attesting to the efficacy and acceptable safety profile of this treatment. Patients with other tremor etiologies are also being treated with MRgFUS, with studies - including an RCT - suggesting parkinsonian tremor in particular responds well to this intervention. Additionally, targets other than the ventral intermediate nucleus, such as the subthalamic nucleus and internal segment of the globus pallidus, have been reported to improve parkinsonian symptoms beyond tremor, including rigidity and bradykinesia. Although MRgFUS is encumbered by certain unique technical challenges, it nevertheless offers significant advantages compared to alternative neurosurgical interventions for tremor. The fast-growing interest in this treatment modality will likely lead to further scientific and technological advancements that could optimize and expand its therapeutic potential.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Artur Vetkas
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Department of Neurosurgery, School of Medicine, University of Tartu, Estonia
| | - Nardin Samuel
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Vanessa Milano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, School of Medicine, KY, USA.,Department of Neurosurgery, Henan University People's Hospital, Henan University School of Medicine, China
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Gavin Jb Elias
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Hisashi Ito
- Department of Neurology, Shonantobu General Hospital, Japan.,Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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15
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Cras TY, Hunink MMG, Dammers R, van Es ACGM, Volovici V, Burke JF, Kremers FCC, Dippel DWJ, Roozenbeek B. Surveillance of Unruptured Intracranial Aneurysms: Cost-Effectiveness Analysis for 3 Countries. Neurology 2022; 99:e890-e903. [PMID: 35654593 DOI: 10.1212/wnl.0000000000200785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance. METHODS We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis. RESULTS Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice. DISCUSSION Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.
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Affiliation(s)
- Tim Yannick Cras
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Myriam M G Hunink
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Ruben Dammers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Adriaan C G M van Es
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Victor Volovici
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - James F Burke
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Femke C C Kremers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Diederik W J Dippel
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bob Roozenbeek
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
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16
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Yamamoto K, Sarica C, Elias GJB, Boutet A, Germann J, Loh A, Joel SE, Bigioni L, Gwun D, Gramer R, Li SX, Zemmar A, Vetkas A, Algarni M, Devenyi G, Chakravarty M, Hynynen K, Scantlebury N, Schwartz ML, Lozano AM, Fasano A. Ipsilateral and axial tremor response to focused ultrasound thalamotomy for essential tremor: clinical outcomes and probabilistic mapping. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328459. [PMID: 35995551 DOI: 10.1136/jnnp-2021-328459] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND MR-guided focused ultrasound (MRgFUS) thalamotomy has been shown to be a safe and effective treatment for essential tremor (ET). OBJECTIVE To investigate the effects of MRgFUS in patients with ET with an emphasis on ipsilateral-hand and axial tremor subscores. METHODS Tremor scores and adverse effects of 100 patients treated between 2012 and 2018 were assessed at 1 week, 3, 12, and 24 months. A subgroup analysis of ipsilateral-hand tremor responders (defined as patients with ≥30% improvement at any time point) and non-responders was performed. Correlations and predictive factors for improvement were analysed. Weighted probabilistic maps of improvement were generated. RESULTS Significant improvement in axial, contralateral-hand and total tremor scores was observed at all study visits from baseline (p<0.0001). There was no significant improvement in ipsilateral subscores. A subset of patients (n=20) exhibited group-level ipsilateral-hand improvement that remained significant through all follow-ups (p<0.001). Multivariate regression analysis revealed that higher baseline scores predict better improvement in ipsilateral-hand and axial tremor. Probabilistic maps demonstrated that the lesion hotspot for axial improvement was situated more medially than that for contralateral improvement. CONCLUSION MRgFUS significantly improved axial, contralateral-hand and total tremor scores. In a subset of patients, a consistent group-level treatment effect was observed for ipsilateral-hand tremor. While ipsilateral improvement seemed to be less directly related to lesion location, a spatial relationship between lesion location and axial and contralateral improvement was observed that proved consistent with the somatotopic organisation of the ventral intermediate nucleus. TRIAL REGISTRATION NUMBERS NCT01932463, NCT01827904, and NCT02252380.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gavin J B Elias
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Jurgen Germann
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Luca Bigioni
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dave Gwun
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert Gramer
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Artur Vetkas
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Neurosurgery, University of Tartu, Tartu, Tartumaa, Estonia
| | - Musleh Algarni
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gabriel Devenyi
- Cerebral Imaging Center, Douglas Mental Health University Institute, Montreal, Quebec, Canada
- Departments of Psychiatry and Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Mallar Chakravarty
- Cerebral Imaging Center, Douglas Mental Health University Institute, Montreal, Quebec, Canada
- Departments of Psychiatry and Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Nadia Scantlebury
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- Krembil Research Institute, 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
- Krembil Research Institute, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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17
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Pohl EDR, Upadhyay N, Kobeleva X, Purrer V, Maurer A, Keil VC, Kindler C, Borger V, Pieper CC, Groetz S, Scheef L, Maciaczyk J, Schild H, Vatter H, Klockgether T, Radbruch A, Attenberger U, Wüllner U, Boecker H. Coherent Structural and Functional Network Changes after Thalamic Lesions in Essential Tremor. Mov Disord 2022; 37:1924-1929. [PMID: 35735240 DOI: 10.1002/mds.29130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/02/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound of the ventral intermediate nucleus is a novel incisionless ablative treatment for essential tremor (ET). OBJECTIVE The aim was to study the structural and functional network changes induced by unilateral sonication of the ventral intermediate nucleus in ET. METHODS Fifteen essential tremor patients (66.2 ± 15.4 years) underwent probabilistic tractography and functional magnetic resonance imaging (MRI) during unilateral postural tremor-eliciting tasks using 3-T MRI before, 1 month (N = 15), and 6 months (N = 10) post unilateral sonication. RESULTS Tractography identified tract-specific alterations within the dentato-thalamo-cortical tract (DTCT) affected by the unilateral lesion after sonication. Relative to the treated hand, task-evoked activation was significantly reduced in contralateral primary sensorimotor cortex and ipsilateral cerebellar lobules IV/V and VI, and vermis. Dynamic causal modeling revealed a significant decrease in excitatory drive from the cerebellum to the contralateral sensorimotor cortex. CONCLUSIONS Thalamic lesions induced by sonication induce specific functional network changes within the DTCT, notably reducing excitatory input to ipsilateral sensorimotor cortex in ET. ©[2022] International Parkinson and Movement Disorder Society. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Emily D R Pohl
- Division "Clinical Functional Imaging," Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Neeraj Upadhyay
- Division "Clinical Functional Imaging," Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Xenia Kobeleva
- Department of Neurology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Veronika Purrer
- Department of Neurology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Angelika Maurer
- Division "Clinical Functional Imaging," Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Vera C Keil
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, VUmc, Amsterdam, the Netherlands
| | - Christine Kindler
- Department of Neurology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Claus C Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Simon Groetz
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Lukas Scheef
- Division "Clinical Functional Imaging," Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Jaroslaw Maciaczyk
- Stereotactic and Functional Neurosurgery, Department of Neurosurgery, University Hospital Bonn, Bonn, Germany.,Division of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Hans Schild
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Thomas Klockgether
- Department of Neurology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Alexander Radbruch
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Ulrike Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Ullrich Wüllner
- Department of Neurology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Henning Boecker
- Division "Clinical Functional Imaging," Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
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18
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Shetty N. Essential Tremor-Do We Have Better Therapeutics? A Review of Recent Advances and Future Directions. Curr Neurol Neurosci Rep 2022; 22:197-208. [PMID: 35235170 DOI: 10.1007/s11910-022-01185-8] [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] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Essential tremor (ET) is a very common condition that significantly impacts quality of life. Current medical treatments are quite limited, and while surgical treatments like deep brain stimulation (DBS) can be very effective, they come with their own limitations as well as procedural risks. This article reviews updates on recent advances and future directions in the treatment of ET. RECENT FINDINGS A new generation of pharmacologic agents specifically designed for ET is in clinical trials. Advances in DBS technology continue to improve this therapy. MRI-guided focused ultrasound (MRgFUS) is now an approved noninvasive ablative treatment for ET that is effective and shows potential for continuing improvement. The first peripheral stimulation device for ET has also now been approved. This article reviews updates on the treatment of ET, encompassing pharmacologic agents in clinical trials, DBS, MRgFUS, and noninvasive stimulation therapies. Recent treatment advances and future directions of development show a great deal of promise for ET therapeutics.
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Affiliation(s)
- Neil Shetty
- Parkinson's Disease and Movement Disorders Center, Department of Neurology, Northwestern University Feinberg School of Medicine, Abbott Hall, 11th Floor, 710 N. Lake Shore Drive, Chicago, IL, 60611, USA.
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19
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Lak AM, Segar DJ, McDannold N, White PJ, Cosgrove GR. Magnetic Resonance Image Guided Focused Ultrasound Thalamotomy. A Single Center Experience With 160 Procedures. Front Neurol 2022; 13:743649. [PMID: 35250802 PMCID: PMC8894664 DOI: 10.3389/fneur.2022.743649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/24/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction MRgFUS thalamotomy has gained popularity as an FDA approved, non-invasive treatment for patients with Essential Tremor and tremor predominant Parkinson's Disease. We present our initial clinical experience with 160 consecutive cases of MRgFUS thalamotomy and describe the clinical outcomes with long term follow-up. Methods A retrospective chart review of all patients who underwent MRgFUS thalamotomy at our institution was performed. CRST Part A tremor scores were obtained pre-operatively and at each follow-up visit along with an assessment of side effects (SE). All patients had a post-operative MRI within 24 h to determine the location, size, and extent of the MRgFUS lesion. Results One hundred and sixty unilateral MRgFUS Thalamotomies (Left, n = 128; Right, n = 32) were performed for medically refractory essential Tremor (n = 150) or tremor predominant Parkinson's disease (n = 10). Mean age at surgery was 75 Years (range: 48-93) and the mean skull density ratio (SDR) was 0.48 (range: 0.32-0.75; median: 0.46). In ET patients, both rest and postural tremor was abolished acutely and remained so at follow-up whereas intention tremor was reduced acutely by 93% below baseline, 87% at 3 months, 83.0% at 1-year, and 78% at 2 years. On post-operative day 1, the most common SE's included imbalance (57%), sensory disturbances (25%), and dysmetria (11%). All adverse events were rated as mild on the Clavien-Dindo Scale and improved over time. At 2-years follow-up, imbalance was seen in 18%, sensory disturbance in 10% and dysmetria in 8% patients. Mean clinical follow-up for all patients was 14 months (range: 1-48 months). Conclusion MRgFUS thalamotomy is a safe and effective procedure for long term improvement of unilateral tremor symptoms, with the most common side-effects being imbalance and sensory disturbance.
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Affiliation(s)
- Asad M. Lak
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - David J. Segar
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nathan McDannold
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Phillip Jason White
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
- Department of Chemistry and Physics, Simmons University, Boston, MA, United States
| | - Garth Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
- *Correspondence: Garth Rees Cosgrove
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20
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Titova NV, Katunina EA, Tairova RT, Sen'ko IV, Dzhafarov VM, Malykhina EA. [The problem of pharmacoresistant tremor in Parkinson's disease and essential tremor]. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:24-30. [PMID: 36279225 DOI: 10.17116/jnevro202212210124] [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] [Indexed: 06/16/2023]
Abstract
MR-guided focused ultrasound (MRg-FUS) is a new noninvasive method for the treatment of contralateral disabling and pharmacoresistant tremor. Clinical studies have confirmed the high efficacy and safety of using MRg-FUS in patients with essential tremor and Parkinson's disease, in short and long-term studies. Advantages of this method in comparison with currently used invasive and noninvasive technics, potential brain target areas, the possibility of bilateral intervention, indications and contraindications are discussed.
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Affiliation(s)
- N V Titova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E A Katunina
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - R T Tairova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Sen'ko
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - V M Dzhafarov
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - E A Malykhina
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
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21
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Alshenqiti U, Alzalabani Y, Siddiqui K, Alfaisal S, Albadrani M. Focused ultrasound and deep brain stimulation for Parkinsonism – Review of literature to investigate tradeoff between safety and efficacy. SAUDI JOURNAL FOR HEALTH SCIENCES 2022. [DOI: 10.4103/sjhs.sjhs_86_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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22
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Segar DJ, Lak AM, Lee S, Harary M, Chavakula V, Lauro P, McDannold N, White J, Cosgrove GR. Lesion location and lesion creation affect outcomes after focused ultrasound thalamotomy. Brain 2021; 144:3089-3100. [PMID: 34750621 DOI: 10.1093/brain/awab176] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/13/2021] [Accepted: 04/05/2021] [Indexed: 11/13/2022] Open
Abstract
MRI-guided focused ultrasound thalamotomy has been shown to be an effective treatment for medication refractory essential tremor. Here, we report a clinical-radiological analysis of 123 cases of MRI-guided focused ultrasound thalamotomy, and explore the relationships between treatment parameters, lesion characteristics and outcomes. All patients undergoing focused ultrasound thalamotomy by a single surgeon were included. The procedure was performed as previously described, and patients were followed for up to 1 year. MRI was performed 24 h post-treatment, and lesion locations and volumes were calculated. We retrospectively evaluated 118 essential tremor patients and five tremor-dominant Parkinson's disease patients who underwent thalamotomy. At 24 h post-procedure, tremor abated completely in the treated hand in 81 essential tremor patients. Imbalance, sensory disturbances and dysarthria were the most frequent acute adverse events. Patients with any adverse event had significantly larger lesions, while inferolateral lesion margins were associated with a higher incidence of motor-related adverse events. Twenty-three lesions were identified with irregular tails, often extending into the internal capsule; 22 of these patients experienced at least one adverse event. Treatment parameters and lesion characteristics changed with increasing surgeon experience. In later cases, treatments used higher maximum power (normalized to skull density ratio), accelerated more quickly to high power, and delivered energy over fewer sonications. Larger lesions were correlated with a rapid rise in both power delivery and temperature, while increased oedema was associated with rapid rise in temperature and the maximum power delivered. Total energy and total power did not significantly affect lesion size. A support vector regression was trained to predict lesion size and confirmed the most valuable predictors of increased lesion size as higher maximum power, rapid rise to high-power delivery, and rapid rise to high tissue temperatures. These findings may relate to a decrease in the energy efficiency of the treatment, potentially due to changes in acoustic properties of skull and tissue at higher powers and temperatures. We report the largest single surgeon series of focused ultrasound thalamotomy to date, demonstrating tremor relief and adverse events consistent with reported literature. Lesion location and volume impacted adverse events, and an irregular lesion tail was strongly associated with adverse events. High-power delivery early in the treatment course, rapid temperature rise, and maximum power were dominant predictors of lesion volume, while total power, total energy, maximum energy and maximum temperature did not improve prediction of lesion volume. These findings have critical implications for treatment planning in future patients.
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Affiliation(s)
- David J Segar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Asad M Lak
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shane Lee
- Department of Neuroscience, Brown University, Providence, RI, USA
| | - Maya Harary
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Vamsidhar Chavakula
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Lauro
- Department of Neuroscience, Brown University, Providence, RI, USA
| | - Nathan McDannold
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason White
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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23
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Sarica C, Fomenko A, Iorio-Morin C, Zemmar A, Yamamoto K, Vetkas A, Lozano AM, Fasano A. Letter to the Editor. Clinical Rating Scale for Tremor: a needed clarification. J Neurosurg 2021; 136:932-933. [PMID: 34740188 DOI: 10.3171/2021.7.jns211783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Can Sarica
- 1Toronto Western Hospital, University of Toronto, ON, Canada
| | - Anton Fomenko
- 1Toronto Western Hospital, University of Toronto, ON, Canada
| | | | - Ajmal Zemmar
- 1Toronto Western Hospital, University of Toronto, ON, Canada.,3Henan University School of Medicine, Zhengzhou, China.,4University of Louisville, School of Medicine, Louisville, KY
| | | | - Artur Vetkas
- 1Toronto Western Hospital, University of Toronto, ON, Canada.,5School of Medicine, University of Tartu, Estonia
| | - Andres M Lozano
- 1Toronto Western Hospital, University of Toronto, ON, Canada.,6Krembil Brain Institute, Toronto, ON, Canada
| | - Alfonso Fasano
- 6Krembil Brain Institute, Toronto, ON, Canada.,8University of Toronto, ON, Canada
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24
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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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25
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Bruno F, Catalucci A, Varrassi M, Arrigoni F, Sucapane P, Cerone D, Pistoia F, Torlone S, Tommasino E, De Santis L, Barile A, Ricci A, Marini C, Splendiani A, Masciocchi C. Comparative evaluation of tractography-based direct targeting and atlas-based indirect targeting of the ventral intermediate (Vim) nucleus in MRgFUS thalamotomy. Sci Rep 2021; 11:13538. [PMID: 34188190 PMCID: PMC8241849 DOI: 10.1038/s41598-021-93058-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/08/2021] [Indexed: 11/12/2022] Open
Abstract
To analyze and compare direct and indirect targeting of the Vim for MRgFUS thalamotomy. We retrospectively evaluated 21 patients who underwent unilateral MRgFUS Vim ablation and required targeting repositioning during the procedures. For each patient, in the three spatial coordinates, we recorded: (i) indirect coordinates; (ii) the coordinates where we clinically observed tremor reduction during the verification stage sonications; (iii) direct coordinates, measured on the dentatorubrothalamic tract (DRTT) at the after postprocessing of DTI data. The agreement between direct and indirect coordinates compared to clinically effective coordinates was evaluated through the Bland–Altman test and intraclass correlation coefficient. The median absolute percentage error was also calculated. Compared to indirect targeting, direct targeting showed inferior error values on the RL and AP coordinates (0.019 vs. 0.079 and 0.207 vs. 0.221, respectively) and higher error values on the SI coordinates (0.263 vs. 0.021). The agreement between measurements was higher for tractography along the AP and SI planes and lower along the RL planes. Indirect atlas-based targeting represents a valid approach for MRgFUS thalamotomy. The direct tractography approach is a valuable aid in assessing the possible deviation of the error in cases where no immediate clinical response is achieved.
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Affiliation(s)
- Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy. .,Italian Society of Medical and Interventional Radiology, SIRM Foundation, Milan, Italy.
| | - Alessia Catalucci
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, L'Aquila, Italy
| | - Marco Varrassi
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, L'Aquila, Italy
| | - Francesco Arrigoni
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | | | | | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | - Silvia Torlone
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | - Emanuele Tommasino
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | - Luca De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | | | - Carmine Marini
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, Italy
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26
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Zibly Z, Averbuch S. MR-Guided High-Intensity Focused Ultrasound Lesioning: MRgHIFU Breathing Life in the Lost Art of Lesioning for Movement Disorders. Neurol India 2021; 68:S202-S205. [PMID: 33318351 DOI: 10.4103/0028-3886.302452] [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: 11/04/2022]
Abstract
Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) is a well-established technology that has been developed during the last decade and is currently used in the treatment of a diverse range of neurodegenerative brain disorders and neuropsychiatric diseases. This innovative noninvasive technology uses nonionizing ultrasound waves to heat and thus ablate brain tissue in selected targets. In comparison with other lesioning and surgical techniques, MRgHIFU has the following advantages: noninvasive, an immediate clinical outcome with no risk of long-standing ionizing radiation injury, no need for general anesthesia, and no device implantation.
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Affiliation(s)
- Zion Zibly
- Department of Neurosurgery, The Functional Neurosurgery Unit, The Focused Ultrasound Institute and Sackler School of Medicine, Tel Aviv University, Israel
| | - Shay Averbuch
- Sackler School of Medicine, Tel Aviv University, Israel
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27
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De Vloo P, Boutet A, Elias GJB, Gramer RM, Joel SE, Llinas M, Kucharczyk W, Fasano A, Hamani C, Lozano AM. Dysgeusia induced and resolved by focused ultrasound thalamotomy: case report. J Neurosurg 2021; 136:215-220. [PMID: 34144526 DOI: 10.3171/2020.11.jns202882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/13/2020] [Indexed: 11/06/2022]
Abstract
Dysgeusia, or distorted taste, has recently been acknowledged as a complication of thalamic ablation or thalamic deep brain stimulation as a treatment of tremor. In a unique patient, left-sided MR-guided focused ultrasound thalamotomy improved right-sided essential tremor but also induced severe dysgeusia. Although dysgeusia persisted and caused substantial weight loss, tremor slowly relapsed. Therefore, 19 months after the first procedure, the patient underwent a second focused ultrasound thalamotomy procedure, which again improved tremor but also completely resolved the dysgeusia. On the basis of normative and patient-specific whole-brain tractography, the authors determined the relationship between the thalamotomy lesions and the medial border of the medial lemniscus-a surrogate for the solitariothalamic gustatory fibers-after the first and second focused ultrasound thalamotomy procedures. Both tractography methods suggested partial and complete disruption of the solitariothalamic gustatory fibers after the first and second thalamotomy procedures, respectively. The tractography findings in this unique patient demonstrate that incomplete and complete disruption of a neural pathway can induce and resolve symptoms, respectively, and serve as the rationale for ablative procedures for neurological and psychiatric disorders.
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Affiliation(s)
- Philippe De Vloo
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,2Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Vlaams-Brabant, Belgium
| | - Alexandre Boutet
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,3Joint Department of Medical Imaging, and
| | - Gavin J B Elias
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
| | - Robert M Gramer
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
| | - Suresh E Joel
- 5General Electric Global Research Center, Bangalore, India
| | - Maheleth Llinas
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
| | | | - Alfonso Fasano
- 4Krembil Research Institute, Toronto, Ontario, Canada.,6Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, and Division of Neurology, University of Toronto, Ontario, Canada; and.,7Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Clement Hamani
- 8Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Andres M Lozano
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
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Jameel A, Bain P, Nandi D, Jones B, Gedroyc W. Device profile of exAblate Neuro 4000, the leading system for brain magnetic resonance guided focused ultrasound technology: an overview of its safety and efficacy in the treatment of medically refractory essential tremor. Expert Rev Med Devices 2021; 18:429-437. [PMID: 33945369 DOI: 10.1080/17434440.2021.1921572] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction: Magnetic Resonance guided Focused UltraSound (MRgFUS) is an emerging technique that utilizes multiple high-energy low-frequency ultrasound beams generated from a multi-element transducer focused onto a single site to cause thermal ablation of the target tissue. The ExAblate Neuro 4000 system is the leading MRgFUS brain system, performing targeted thermal ablation on specific nuclei in the brain. Its precision targeting opens up new and exciting possibilities for future treatments of a wide range of neurological diseases. Areas covered: This article aims to introduce the non-expert reader (clinician and non-clinicians) to the role of the ExAblate Neuro 4000 System in brain MRgFUS. The current clinical uses of the ExAblate system in the brain are explored with a particular focus on Essential Tremor, where internationally there is most experience, this includes reference to current literature. The safety and efficacy of MRgFUS treatments are explored and the challenges the ExAblate system must overcome to balance these juxtaposed outcomes.Expert opinion: We describe the hopes for future clinical uses of the ExAblate Neuro 4000 system to treat neurological disease and consider further advancements in MRgFUS transducer technology that may open up new exciting frontiers within the brain.
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Affiliation(s)
- Ayesha Jameel
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - Peter Bain
- Department of Neurosciences, Division of Brain Sciences, Imperial College London, London UK
| | - Dipankar Nandi
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, London, UK
| | - Brynmor Jones
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - Wladyslaw Gedroyc
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
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Magnetic resonance-guided focused ultrasound treatment for essential tremor shows sustained efficacy: a meta-analysis. Neurosurg Rev 2021; 45:533-544. [PMID: 33978922 DOI: 10.1007/s10143-021-01562-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/12/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Although magnetic resonance-guided focused ultrasound (MRgFUS) is a viable treatment option for essential tremor, some studies note a diminished treatment benefit over time. A PubMed search was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if hand tremor scores (HTS), total Clinical Rating Scale for Tremor (CRST) scores, or Quality of Life in Essential Tremor Questionnaire (QUEST) scores at regular intervals following MRgFUS treatment for essential tremor were documented. Data analyses included a random effects model of meta-analysis and mixed-effects model of meta-regression. Twenty-one articles reporting HTS for 395 patients were included. Mean pre-operative HTS was 19.2 ± 5.0. Mean HTS at 3 months post-treatment was 7.4 ± 5.0 (61.5% improvement, p < 0.001). Treatment effect was mildly decreased at 36 months at 9.1 ± 5.4 (8.8% reduction). Meta-regression of time since treatment as a modifier of HTS revealed a downward trend in effect size, though this was not statistically significant (p = 0.208). Only 4 studies included follow-up ≥ 24 months. Thirteen included articles reported total CRST scores with standardized follow-up for 250 patients. Mean pre-operative total CRST score decreased by 46.2% at 3 months post-treatment (p < 0.001). Additionally, mean QUEST scores at 3 months post-treatment significantly improved compared to baseline (p < 0.001). HTS is significantly improved from baseline ≥ 24 months post-treatment and possibly ≥ 48 months post-treatment. There is a current paucity of long-term CRST and QUEST score reporting in the literature.
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Abe K, Horisawa S, Yamaguchi T, Hori H, Yamada K, Kondo K, Furukawa H, Kamada H, Kishima H, Oshino S, Mochizuki H, Kanemoto M, Hirabayashi H, Fukutome K, Ohnishi H, Igase K, Matsubara I, Ohnishi T, Sadamoto K, Taira T. Focused Ultrasound Thalamotomy for Refractory Essential Tremor: A Japanese Multicenter Single-Arm Study. Neurosurgery 2021; 88:751-757. [PMID: 33469648 DOI: 10.1093/neuros/nyaa536] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/10/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Several feasibility studies and a randomized, controlled, multicenter trial have demonstrated the safety and efficacy of unilateral transcranial magnetic resonance-guided focused ultrasound (FUS) lesioning of the ventral intermediate thalamic nucleus in treating essential tremor. OBJECTIVE To evaluate the safety and efficacy of FUS thalamotomy in a Japanese patient cohort through a prospective, multicenter, single-arm confirmatory trial. METHODS A total of 35 patients with disabling refractory essential tremor underwent unilateral FUS thalamotomy and were followed up for 12 post-treatment months. Safety was measured as the incidence and severity of treatment-related adverse events. Efficacy was measured as the tremor severity and quality of life improvements using the Clinical Rating Scale for Tremor and Questionnaire for Essential Tremor. RESULTS The mean skull density ratio (SDR) was 0.47. There was a significant decrease in the mean postural tremor score of the treated hand from baseline to 12 mo by 56.4% (95% CI: 46.7%-66.1%; P < .001), which was maintained at last follow-up. Quality of life improved by 46.3% (mean overall Questionnaire for Essential Tremor score of 17.4 [95% CI: 12.1-22.7]) and there were no severe adverse events. The most frequent adverse event was gait disturbance and all events resolved. CONCLUSION Unilateral FUS thalamotomy allowed significant and sustained tremor relief and improved the quality of life with an outstanding safety profile. The observed safety and efficacy of FUS thalamotomy were comparable to those reported in a previous multicenter study with a low SDR, and inclusion of the low SDR group did not affect effectiveness.
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Affiliation(s)
- Keiichi Abe
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shiro Horisawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Hiroki Hori
- Shinyurigaoka General Hospital, Kanagawa, Japan
| | - Kazumichi Yamada
- Division of Speech-Language-Hearing Therapy, Department of Rehabilitation, Faculty of Health Science, Kumamoto Health Science University, Chuo-ku, Japan
| | - Kimito Kondo
- Department of Neurology, Hokuto Hospital, Obihiro, Japan
| | | | - Hajime Kamada
- Department of Neurology, Hokuto Hospital, Obihiro, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoru Oshino
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Hidehiro Hirabayashi
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Kenji Fukutome
- Department of Neurosurgery, Ohnishi Neurological Center, Hyogo, Japan
| | - Hideyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Hyogo, Japan
| | - Keiji Igase
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Ichiro Matsubara
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Takanori Ohnishi
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Kazuhiko Sadamoto
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Agrawal M, Garg K, Samala R, Rajan R, Naik V, Singh M. Outcome and Complications of MR Guided Focused Ultrasound for Essential Tremor: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:654711. [PMID: 34025558 PMCID: PMC8137896 DOI: 10.3389/fneur.2021.654711] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Magnetic resonance guided focused ultrasound (MRgFUS) is a relatively novel technique to treat essential tremor (ET). The objective of this review was to analyze the efficacy and the safety profile of MRgFUS for ET. Methods: A systematic literature review was done. The post procedure changes in the Clinical Rating Scale for Tremor (CRST) score, hand score, disability and quality of life scores were analyzed. Results: We found 29 studies evaluating 617 patients. DTI based targeting was utilized in six cohorts. A significant difference was observed in the pooled standard mean difference between the pre and postoperative total CRST score (p-value < 0.001 and 0.0002), hand score (p-value 0.03 and 0.02); and the disability at 12 months (p-value 0.01). Head pain and dizziness were the most in procedure complications. The immediate pooled proportion of ataxia was 50%, while it was 20% for sensory complications, which, respectively, declined to 31 and 13% on long term follow up. A significant reduction (p = 0.03) in immediate ataxia related complications was seen with DTI targeting. Conclusion: MRgFUS for ET seems to be an effective procedure for relieving unilateral tremor. Use of DTI based targeting revealed a significant reduction in post procedure ataxia related complications as compared to traditional targeting techniques. Analysis of other complications further revealed a decreasing trend on follow up.
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Affiliation(s)
- Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Roopa Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Naik
- Department of Neurosurgery, Bangalore Medical College, Bangalore, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Máñez-Miró JU, Rodríguez-Rojas R, Del Álamo M, Martínez-Fernández R, Obeso JA. Present and future of subthalamotomy in the management of Parkinson´s disease: a systematic review. Expert Rev Neurother 2021; 21:533-545. [PMID: 33788645 DOI: 10.1080/14737175.2021.1911649] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The subthalamic nucleus (STN) is known to be involved in the pathophysiology of Parkinson´s disease and by reducing its abnormal activity, normal output of basal ganglia can be restored along with improvement in PD cardinal motor features. Deep brain stimulation of the STN is currently the main surgical procedure for PD with motor complications, but lesioning can be an alternative.Areas covered: Here, the authors systematically review the current evidence regarding subthalamotomy both with radiofrequency and, more recently, with focused ultrasound (FUS) for the treatment of PD.Expert opinion: Unilateral subthalamotomy for the treatment of PD motor features can be considered a viable option in asymmetric patients, particularly with FUS which allows a minimally invasive safe and effective ablation of the STN. Risk of inducing dyskinesia (i.e., hemichorea/ballism) may be strikingly reduced when lesions enlarge dorsally to impinge on pallidothalamic fibers.
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Affiliation(s)
- Jorge U Máñez-Miró
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - Rafael Rodríguez-Rojas
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - Marta Del Álamo
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - R Martínez-Fernández
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - José A Obeso
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain.,CEU-San Pablo University, Móstoles, Madrid, Spain
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Cacho-Asenjo E, Honorato-Cia C, Nuñez-Cordoba JM, Fernandez-Martinez M, Gonzalez-Quarante LH, Aviles-Olmos I, Gorospe MA, Panadero A, Rodríguez-Oroz MC, Guridi J, Martinez-Simon A. Factors Associated with Headache and Nausea During Magnetic Resonance-Guided Focused Ultrasound for Tremor. Mov Disord Clin Pract 2021; 8:701-708. [PMID: 34307742 DOI: 10.1002/mdc3.13210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/07/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background During magnetic resonance-guided focused ultrasound for essential or parkinsonian tremor, adverse events (headache, nausea/vomiting, or anxiety) may alter the outcome of the procedure despite being mostly transient and mild. Objectives Our aim was to analyze the relationship between demographic, procedural, and anesthetic characteristics with magnetic resonance/ultrasound-related events. Methods This was a retrospective study at the Clinica Universidad de Navarra of patients undergoing thalamotomy with magnetic resonance-guided focused ultrasound between September 2018 and October 2019. The anesthesia protocol included headache and nausea/vomiting prophylaxis and rescue therapy. Dexmedetomidine was used for anxiolysis in some patients after thorough multidisciplinary assessment. Results A total of 123 patients were included. Headache was directly related to skull density ratio (P < 0.001) and skull thickness (P = 0.02). Patients with a skull density ratio less than 0.48 had 3 times the odds of experiencing moderate or severe headache (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.21-7.82) and had a higher odds of aborting sonication due to pain. Sex was associated with increased nausea (P = 0.007). Women had 4 times the odds of nausea than men (OR, 4.4; 95% CI, 1.61-12.11). Dexmedetomidine did not reduce headache or nausea incidence. Patients who received dexmedetomidine had a higher number (P = 0.01) and total minutes of sonication (P = 0.01). Conclusions Patients with lower skull density ratios and higher skull thicknesses could benefit from an aggressive analgesic prophylaxis. Women are more likely to experience nausea. Dexmedetomidine did not reduce headache and nausea, but increased the number and duration of sonications. Its exact effect on tremor is still unclear.
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Affiliation(s)
- Elena Cacho-Asenjo
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain.,Instituto de Investigación Sanitaria de Navarra Pamplona Spain
| | - Cristina Honorato-Cia
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain.,Instituto de Investigación Sanitaria de Navarra Pamplona Spain
| | - Jorge M Nuñez-Cordoba
- Research Support Service, Central Clinical Trials Unit Clinica Universidad de Navarra Pamplona Spain
| | | | | | | | | | - Alfredo Panadero
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain
| | | | - Jorge Guridi
- Department of Neurosurgery Clinica Universidad de Navarra Pamplona Spain
| | - Antonio Martinez-Simon
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain.,Instituto de Investigación Sanitaria de Navarra Pamplona Spain
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Hori H, Iwamuro H, Nakano M, Ouchi T, Kawahara T, Taira T, Abe K, Iijima K, Yamaguchi T. Correction of the skull density ratio for transcranial MRI-guided focused ultrasound thalamotomy: clinical significance of predicting therapeutic temperature. J Neurosurg 2021; 135:1436-1444. [PMID: 33668032 DOI: 10.3171/2020.9.jns201109] [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: 04/27/2020] [Accepted: 09/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In transcranial magnetic resonance imaging-guided focused ultrasound (TcMRgFUS), a high skull density ratio (SDR) is advantageous to achieve a sufficiently high temperature at the target. However, it is not easy to estimate the temperature rise because the SDR shows different values depending on the reconstruction filter used. The resolution characteristic of a computed tomography (CT) image depends on a modulation transfer function (MTF) defined by the reconstruction filter. Differences in MTF induce unstable SDRs. The purpose of this study was both to standardize SDR by developing a method to correct the MTF and to enable effective patient screening prior to TcMRgFUS treatment and more accurate predictions of focal temperature. METHODS CT images of a skull phantom and five subjects were obtained using eight different reconstruction filters. A frequency filter (FF) was calculated using the MTF of each reconstruction filter, and the validity of SDR standardization was evaluated by comparing the variation in SDR before and after FF correction. Subsequently, FF processing was similarly performed using the CT images of 18 patients who had undergone TcMRgFUS, and statistical analyses were performed comparing the relationship between the SDRs before and after correction and the maximum temperature in the target during TcMRgFUS treatment. RESULTS The FF was calculated for each reconstruction filter based on one manufacturer's BONE filter. In the CT images of the skull phantom, the SDR before FF correction with five of the other seven reconstruction filters was significantly smaller than that with the BONE filter (p < 0.01). After FF correction, however, a significant difference was recognized under only one condition. In the CT images of the five subjects, variation of the SDR due to imaging conditions was significantly improved after the FF correction. In 18 cases treated with TcMRgFUS, there was no correlation between SDR before FF correction and maximum temperature (rs = 0.31, p > 0.05); however, a strong positive correlation was observed after FF correction (rs = 0.71, p < 0.01). CONCLUSIONS After FF correction, the difference in SDR due to the reconstruction filter used is smaller, and the correlation with temperature is stronger. Therefore, the SDR can be standardized by applying the FF, and the maximum temperature during treatment may be predicted more accurately.
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Affiliation(s)
| | - Hirokazu Iwamuro
- 6Department of Neurosurgery, Juntendo University, Bunkyo, Tokyo; and
| | | | | | | | - Takaomi Taira
- 7Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Keiichi Abe
- 7Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Ken Iijima
- 5Department of Diagnostic Radiology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
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Preoperative imaging findings in patients undergoing transcranial magnetic resonance imaging-guided focused ultrasound thalamotomy. Sci Rep 2021; 11:2524. [PMID: 33510338 PMCID: PMC7843629 DOI: 10.1038/s41598-021-82271-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 01/01/2021] [Indexed: 11/09/2022] Open
Abstract
The prevalence and impact of imaging findings detected during screening procedures in patients undergoing transcranial MR-guided Focused Ultrasound (tcMRgFUS) thalamotomy for functional neurological disorders has not been assessed yet. This study included 90 patients who fully completed clinical and neuroradiological screenings for tcMRgFUS in a single-center. The presence and location of preoperative imaging findings that could impact the treatment were recorded and classified in three different groups according to their relevance for the eligibility and treatment planning. Furthermore, tcMRgFUS treatments were reviewed to evaluate the number of transducer elements turned off after marking as no pass regions the depicted imaging finding. A total of 146 preoperative imaging findings in 79 (87.8%) patients were detected in the screening population, with a significant correlation with patients' age (rho = 483, p < 0.001). With regard of the group classification, 119 (81.5%), 26 (17.8%) were classified as group 1 or 2, respectively. One patient had group 3 finding and was considered ineligible. No complications related to the preoperative imaging findings occurred in treated patients. Preoperative neuroradiological findings are frequent in candidates to tcMRgFUS and their identification may require the placement of additional no-pass regions to prevent harmful non-targeted heating.
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Abstract
Essential tremor is one of the most common tremor syndromes. According to the recent tremor classification, tremor as a symptom is defined as an involuntary, rhythmic, oscillatory movement of a body part and is classified along two axes: axis 1-defining syndromes based on the clinical features such as historical features, tremor characteristics, associated signs, and laboratory tests; and axis 2-classifying the etiology (Bhatia et al., Mov Disord 33:75-87, 2018). The management of this condition has two major approaches. The first is to exclude treatable etiologies, as particularly during the onset of this condition the presentation of a variety of etiologies can be with monosymptomatic tremor. Once the few etiologies with causal treatments are excluded, all further treatment is symptomatic. Shared decision-making with enabling the patient to knowledgeably choose treatment options is needed to customize the management. Mild to moderate tremor severity can sometimes be controlled with occupational treatment, speech therapy of psychotherapy, or adaptation of coping strategy. First-line pharmacological treatments include symptomatic treatment with propranolol, primidone, and topiramate. Botulinum toxin is for selected cases. Invasive treatments for essential tremor should be considered for severe tremors. They are generally accepted as the most powerful interventions and provide not only improvement of tremor but also a significant improvement of life quality. The current standard is deep brain stimulation (DBS) of the thalamic and subthalamic region. Focused ultrasound thalamotomy is a new therapy attracting increasing interest. Radiofrequency lesioning is only rarely done if DBS or focused ultrasound is not possible. Radiosurgery is not well established. We present our treatment algorithm.
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Affiliation(s)
- Franziska Hopfner
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Rosalind-Fraenklinstr. 10, 24105, Kiel, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Günther Deuschl
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Rosalind-Fraenklinstr. 10, 24105, Kiel, Germany.
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Outcomes and Adverse Effects of Deep Brain Stimulation on the Ventral Intermediate Nucleus in Patients with Essential Tremor. Neural Plast 2020; 2020:2486065. [PMID: 32802034 PMCID: PMC7416257 DOI: 10.1155/2020/2486065] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/24/2020] [Accepted: 07/03/2020] [Indexed: 01/17/2023] Open
Abstract
Objective This study was aimed at identifying the potential outcome predictors, comparing the efficacy in patients with different tremor characteristics, and summarizing the adverse effect rates (AERs) of deep brain stimulation on the ventral intermediate nucleus (VIM-DBS) for essential tremor (ET). Methods An extensive search of articles published to date in 2019 was conducted, and two main aspects were analyzed. Improvement was calculated as a percentage of change in any objective tremor rating scale (TRS) and analyzed by subgroup analyses of patients' tremor characteristics, laterality, and stimulation parameters. Furthermore, the AERs were analyzed as follows: the adverse effects (AEs) were classified as stimulation-related, surgical-related, or device-related effects. A simple regression analysis was used to identify the potential prognostic factors, and a two-sample mean-comparison test was used to verify the statistical significance of the subgroup analyses. Results Forty-six articles involving 1714 patients were included in the meta-analysis. The pooled improvement in any objective TRS score was 61.3% (95% CI: 0.564-0.660) at the mean follow-up visit (20.0 ± 17.3 months). The midline and extremity symptoms showed consistent improvement (P = 0.440), and the results of the comparison of postural and kinetic tremor were the same (P = 0.219). In addition, the improvement in rest tremor was similar to that in action tremor (OR = 2.759, P = 0.120). In the simple regression analysis, the preoperative Fahn-Tolosa-Marin Tremor Rating Scale (FTM-TRS) scores and follow-up time were negatively correlated with the percentage change in any objective TRS score (P < 0.05). The most common adverse event was dysarthria (10.5%), which is a stimulation-related AE (23.6%), while the rates of the surgical-related and device-related AEs were 6.4% and 11.5%, respectively. Conclusion VIM-DBS is an efficient and safe surgical method in ET, and the efficacy was not affected by the body distribution of tremor, age at surgery, and disease duration. Lower preoperative FTM-TRS scores likely indicate greater improvement, and the effect of VIM-DBS declines over time.
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38
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Magnetic resonance-guided focused ultrasound for movement disorders: clinical and neuroimaging advances. Curr Opin Neurol 2020; 33:488-497. [DOI: 10.1097/wco.0000000000000840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Murase M, Tamura R, Kuranari Y, Sato M, Ohara K, Morimoto Y, Yoshida K, Toda M. Novel histopathological classification of meningiomas based on dural invasion. J Clin Pathol 2020; 74:238-243. [PMID: 32546547 DOI: 10.1136/jclinpath-2020-206592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/03/2022]
Abstract
AIMS Histological invasion into the adjacent brain parenchyma is frequently investigated in meningioma because it is an important morphological criterion for grade II meningioma according to the 2016 WHO classification. However, few studies have focused on dural invasion of meningiomas. Herein, we propose a novel histopathological classification based on dural invasion of meningiomas. METHODS Forty-nine cases with WHO grade I meningiomas who underwent Simpson grade I removal were collected. After the meningeal layer (ML) and periosteal layer (PL) of dura mater were visualised by Masson's trichrome stain, we evaluated the depth (to the ML and PL) and the patterns (1, expanding; 2, infiltrating) of dural invasion of meningiomas using serial paraffin sections. Invasion-associated markers, including Ki-67, matrix metalloproteinase (MMP)-1, MMP-9 and MMP-13, aquaporin 1 and Na-K-2Cl cotransporter, were quantitatively analysed by immunohistochemistry. RESULTS Thirty-five cases (71.4%) showed the dural invasion. In 27 of these 35 cases (77.1%), dural invasion was localised in ML. Type 1 (expanding type) and type 2 (infiltrating type) invasions were observed in 23 and 12 cases, respectively. The recurrence rate in cases with type 2 invasion was significantly higher than that in cases with type 1 invasion. The percentage of MMP-1-positive tumour cells was also significantly higher in cases with dural invasion than those without, suggesting involvement of MMP-1 in dural invasion. CONCLUSIONS We quantitatively evaluated the depth and patterns of dural invasion in meningiomas. The patterns of dural invasion were associated with meningioma recurrence.
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Affiliation(s)
- Makoto Murase
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuki Kuranari
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kentaro Ohara
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yukina Morimoto
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Gagliardo C, Cannella R, Quarrella C, D'Amelio M, Napoli A, Bartolotta TV, Catalano C, Midiri M, Lagalla R. Intraoperative imaging findings in transcranial MR imaging-guided focused ultrasound treatment at 1.5T may accurately detect typical lesional findings correlated with sonication parameters. Eur Radiol 2020; 30:5059-5070. [PMID: 32346791 DOI: 10.1007/s00330-020-06712-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/28/2019] [Accepted: 02/04/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess the intraoperative neuroimaging findings in patients treated with transcranial MR-guided focused ultrasound (tcMRgFUS) thalamotomy using 1.5T equipment in comparison with the 48-h follow-up. METHODS Fifty prospectively enrolled patients undergoing unilateral tcMRgFUS thalamotomy for either medication-refractory essential tremor (n = 39) or Parkinson tremor (n = 11) were included. Two radiologists evaluated the presence and size of concentric lesional zones (zone I, zone II, and zone III) on 2D T2-weighted sequences acquired intraoperatively after the last high-energy sonication and at 48 h. Sonication parameters including number of sonications, delivered energy, and treatment temperatures were also recorded. Differences in lesion pattern and size were assessed using the McNemar test and paired t test, respectively. RESULTS Zones I, II, and III were visualized in 34 (68%), 50 (100%), and 44 (88%) patients, and 31 (62%), 50 (100%), and 45 (90%) patients after the last high-energy sonication for R1 and R2, respectively. All three concentric zones were visualized intraoperatively in 56-58% of cases. Zone I was significantly more commonly visualized at 48 h (p < 0.001). Diameter of zones I and II and the thickness of zone III significantly increased at 48 h (p < 0.001). Diameters of zones I and II measured intraoperatively demonstrated significant correlation with thermal map temperatures (p ≤ 0.001). Maximum temperature significantly correlated with zone III thickness at 48 h. A threshold of 60.5° had a sensitivity of 56.5-66.7% and a specificity of 70.5-75.5% for thickness > 6 mm at 48 h. CONCLUSIONS Intraoperative imaging may accurately detect typical lesional findings, before completing the treatment. These imaging characteristics significantly correlate with sonication parameters and 48-h follow-up. KEY POINTS • Intraoperative T2-weighted images allow the visualization of the zone I (coagulation necrosis) in most of the treated patients, while zone II (cytotoxic edema) is always detected. • Lesion size depicted with intraoperative transcranial MRgFUS imaging correlates well with procedure parameters. • Intraoperative transcranial MRgFUS imaging may have a significant added value for treating physicians.
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Affiliation(s)
- Cesare Gagliardo
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Cettina Quarrella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Marco D'Amelio
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Alessandro Napoli
- Department of Radiological, Oncological and Anatomopathological Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Tommaso Vincenzo Bartolotta
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Anatomopathological Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Massimo Midiri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Roberto Lagalla
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
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Bhansali AP, Gwinn RP. Ablation: Radiofrequency, Laser, and HIFU. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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42
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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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Olfati N, Shoeibi A, Abdollahian E, Ahmadi H, Hoseini A, Akhlaghi S, Vakili V, Foroughipour M, Rezaeitalab F, Farzadfard MT, Layegh P, Naseri S. Cerebellar repetitive transcranial magnetic stimulation (rTMS) for essential tremor: A double-blind, sham-controlled, crossover, add-on clinical trial. Brain Stimul 2019; 13:190-196. [PMID: 31624048 DOI: 10.1016/j.brs.2019.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/28/2019] [Accepted: 10/03/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND There is controversial evidence about the effect of cerebellar low-frequency stimulation in patients with essential tremor (ET). OBJECTIVES In this study we assessed safety and effectiveness of 1 Hz (low-frequency) cerebellar repetitive transcranial magnetic stimulation (rTMS) on tremor severity in patients with essential tremor in a sham-controlled crossover trial. METHODS A total of 23 patients assigned into two groups to receive either sham (n = 10) or rTMS (n = 13) treatment, with crossing over after a two-month washout period. Intervention consisted of 900 pulses of 1 Hz rTMS at 90% resting motor threshold or the same protocol of sham stimulation over each cerebellar hemisphere for 5 consecutive days. Tremor severity was assessed by Fahn-Tolosa-Marin (FTM) scale at baseline and at days 5, 12 and 30 after intervention. The FTM consists of 3 subscales including tremor severity rating, performance of motor tasks, and functional disability. Carry-over and treatment effects were analyzed using independent samples t-test. RESULTS There was no significant improvement in the total FTM scores in rTMS compared to the sham stimulation on day 5 (p = 0.132), day 12 (p = 0.574), or day 30 (p = 0.382). Similarly, FTM subscales, including tremor severity rating, motor tasks, and functional disability did not improve significantly after rTMS treatment. Mild headache and local pain were the most frequent adverse events. CONCLUSION Although cerebellar rTMS seems to have acceptable safety when used in ET patients, this study could not prove any efficacy for it in reduction of tremor in these patients. Larger studies are needed to evaluate efficacy of this therapeutic intervention and to provide evidence about the optimal stimulation parameters.
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Affiliation(s)
- Nahid Olfati
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Ali Shoeibi
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Ebrahim Abdollahian
- Department of Psychiatry, Faculty of Medicine, Mashhad University of Medical Sciences, Psychiatry and Behavioral Sciences Research Center, Ibn-Sina Medical Center, Mashhad, Iran.
| | - Hamideh Ahmadi
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Alireza Hoseini
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Saeed Akhlaghi
- Department of Psychiatry, Faculty of Medicine, Mashhad University of Medical Sciences, Psychiatry and Behavioral Sciences Research Center, Ibn-Sina Medical Center, Mashhad, Iran.
| | - Vida Vakili
- Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Mohsen Foroughipour
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Fariborz Rezaeitalab
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Mohammad-Taghi Farzadfard
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Parvaneh Layegh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Quaem Medical Center, Mashhad, Iran.
| | - Shahrokh Naseri
- Department of Medical Physics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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44
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Sharma S, Pandey S. Treatment of essential tremor: current status. Postgrad Med J 2019; 96:84-93. [DOI: 10.1136/postgradmedj-2019-136647] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/14/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Essential tremor is the most common cause of tremor involving upper limbs, head and voice. The first line of treatment for limb tremor is pharmacotherapy with propranolol or primidone. However, these two drugs reduce the tremor severity by only half. In medication refractory and functionally disabling tremor, alternative forms of therapy need to be considered. Botulinum toxin injections are likely efficacious for limb, voice and head tremor but are associated with side effects. Surgical interventions include deep brain stimulation; magnetic resonance-guided focused ultrasound and thalamotomy for unilateral and deep brain stimulation for bilateral procedures. Recent consensus classification for essential tremor has included a new subgroup, ‘Essential tremor plus’, who have associated subtle neurological ‘soft signs’, such as dystonic posturing of limbs and may require a different treatment approach. In this review, we have addressed the current management of essential tremor with regard to different anatomical locations of tremor as well as different modalities of treatment.
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45
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Foffani G, Trigo‐Damas I, Pineda‐Pardo JA, Blesa J, Rodríguez‐Rojas R, Martínez‐Fernández R, Obeso JA. Focused ultrasound in Parkinson's disease: A twofold path toward disease modification. Mov Disord 2019; 34:1262-1273. [DOI: 10.1002/mds.27805] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/14/2019] [Accepted: 06/27/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Guglielmo Foffani
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- Hospital Nacional de Parapléjicos Toledo Spain
| | - Inés Trigo‐Damas
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- CIBERNEDInstituto de Salud Carlos III Madrid Spain
| | - José A. Pineda‐Pardo
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- CIBERNEDInstituto de Salud Carlos III Madrid Spain
| | - Javier Blesa
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- CIBERNEDInstituto de Salud Carlos III Madrid Spain
| | - Rafael Rodríguez‐Rojas
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- CIBERNEDInstituto de Salud Carlos III Madrid Spain
| | - Raul Martínez‐Fernández
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- CIBERNEDInstituto de Salud Carlos III Madrid Spain
| | - José A. Obeso
- CINACHospital Universitario HM Puerta del Sur, Móstoles, Universidad CEU‐San Pablo Madrid Spain
- CIBERNEDInstituto de Salud Carlos III Madrid Spain
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Schreglmann SR, Bhatia KP, Hägele-Link S, Werner B, Martin E, Kägi G. Letter to the Editor. Errors in the meta-analysis of outcomes and complications of MRgFUS. Neurosurg Focus 2019; 45:E15. [PMID: 29961390 DOI: 10.3171/2018.3.focus1898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sebastian R Schreglmann
- 1University College London (UCL), Institute of Neurology, London, United Kingdom.,2Kantonsspital St. Gallen, St. Gallen, Switzerland; and
| | - Kailash P Bhatia
- 1University College London (UCL), Institute of Neurology, London, United Kingdom
| | | | - Beat Werner
- 3Center for Focused Ultrasound, University of Zurich, Children's Hospital Zurich, Switzerland
| | - Ernst Martin
- 3Center for Focused Ultrasound, University of Zurich, Children's Hospital Zurich, Switzerland
| | - Georg Kägi
- 2Kantonsspital St. Gallen, St. Gallen, Switzerland; and
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Abstract
Essential tremor is one of the most common movement disorders in adults and can affect both children and adults. An updated consensus statement in 2018 redefined essential tremor as an isolated action tremor present in bilateral upper extremities for at least three years. Tremor may also be present in other locations, commonly the neck or the vocal cords. Patients with additional neurologic symptoms are now categorized as "essential tremor plus." Additional clinical features associated with the condition include but are not limited to cognitive impairment, psychiatric disorders, and hearing loss. When treatment is needed, propranolol and primidone are considered first line treatments. Patients who are severely affected are often offered deep brain stimulation. Although the ventral intermediate nucleus of the thalamus is the traditional surgical target, the caudal zona incerta is also being studied as a possible superior alternative. Magnetic resonance imaging guided high intensity focused ultrasound is a newer surgical alternative that may be ideal for patients with substantial medical comorbidities. Current research explores novel oral treatments, chemodenervation, and noninvasive neuromodulation for treatment of essential tremor.
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Affiliation(s)
- Vicki Shanker
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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48
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Altinel Y, Alkhalfan F, Qiao N, Velimirovic M. Outcomes in Lesion Surgery versus Deep Brain Stimulation in Patients with Tremor: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 123:443-452.e8. [DOI: 10.1016/j.wneu.2018.11.175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022]
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49
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Kumar KK, Bhati MT, Ravikumar VK, Ghanouni P, Stein SC, Halpern CH. MR-Guided Focused Ultrasound Versus Radiofrequency Capsulotomy for Treatment-Refractory Obsessive-Compulsive Disorder: A Cost-Effectiveness Threshold Analysis. Front Neurosci 2019; 13:66. [PMID: 30792625 PMCID: PMC6374333 DOI: 10.3389/fnins.2019.00066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 01/22/2019] [Indexed: 01/28/2023] Open
Abstract
Meta-analytic techniques support neuroablation as a promising therapy for treatment-refractory obsessive-compulsive disorder (OCD). This technique appears to offer a more favorable complication rate and higher utility than deep brain stimulation. Moreover, these pooled findings suggest that bilateral radiofrequency (RF) capsulotomy has marginally greater efficacy than stereotactic radiosurgery or cingulotomy. MR-guided focused ultrasound (MRgFUS) capsulotomy is an emerging approach with a potentially more favorable profile than RF ablation and radiosurgery, with preliminary data suggesting safety and efficacy. As a clinical trial is being developed, our study examined the cost and clinical parameters necessary for MRgFUS capsulotomy to be a more cost-effective alternative to RF capsulotomy. A decision analytical model of MRgFUS with RF capsulotomy for OCD was performed using outcome parameters of percent surgical improvement in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score, complications, and side effects. The analysis compared measured societal costs, derived from Medicare reimbursement rates, and effectiveness, based on published RF data. Effectiveness was defined as the degree to which MRgFUS lowered Y-BOCS score. Given that MRgFUS is a new therapy for OCD with scant published data, theoretical risks of MRgFUS capsulotomy were derived from published essential tremor outcomes. Sensitivity analysis yielded cost, effectiveness, and complication rates as critical MRgFUS parameters defining the cost-effectiveness threshold. Literature search identified eight publications (162 subjects). The average reduction of preoperative Y-BOCS score was 56.6% after RF capsulotomy with a 22.6% improvement in utility, a measure of quality of life. Complications occurred in 16.2% of RF cases. In 1.42% of cases, complications were considered acute-perioperative and incurred additional hospitalization cost. The adverse events, including neurological and neurobehavioral changes, in the other 14.8% of cases did not incur further costs, although they impacted utility. Rollback analysis of RF capsulotomy yielded an expected effectiveness of 0.212 quality-adjusted life years/year at an average cost of $24,099. Compared to RF capsulotomy, MRgFUS was more cost-effective under a range of possible cost and complication rates. While further study will be required, MRgFUS lacks many of the inherent risks associated with more invasive modalities and has potential as a safe and cost-effective treatment for OCD.
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Affiliation(s)
- Kevin K Kumar
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Mahendra T Bhati
- Department of Neurosurgery, Stanford University, Stanford, CA, United States.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | - Vinod K Ravikumar
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Pejman Ghanouni
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
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Jung NY, Chang JW. Magnetic Resonance-Guided Focused Ultrasound in Neurosurgery: Taking Lessons from the Past to Inform the Future. J Korean Med Sci 2018; 33:e279. [PMID: 30369860 PMCID: PMC6200905 DOI: 10.3346/jkms.2018.33.e279] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 09/13/2018] [Indexed: 11/20/2022] Open
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) is a new emerging neurosurgical procedure applied in a wide range of clinical fields. It can generate high-intensity energy at the focal zone in deep body areas without requiring incision of soft tissues. Although the effectiveness of the focused ultrasound technique had not been recognized because of the skull being a main barrier in the transmission of acoustic energy, the development of hemispheric distribution of ultrasound transducer phased arrays has solved this issue and enabled the performance of true transcranial procedures. Advanced imaging technologies such as magnetic resonance thermometry could enhance the safety of MRgFUS. The current clinical applications of MRgFUS in neurosurgery involve stereotactic ablative treatments for patients with essential tremor, Parkinson's disease, obsessive-compulsive disorder, major depressive disorder, or neuropathic pain. Other potential treatment candidates being examined in ongoing clinical trials include brain tumors, Alzheimer's disease, and epilepsy, based on MRgFUS abilities of thermal ablation and opening the blood-brain barrier. With the development of ultrasound technology to overcome the limitations, MRgFUS is gradually expanding the therapeutic field for intractable neurological disorders and serving as a trail for a promising future in noninvasive and safe neurosurgical care.
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Affiliation(s)
- Na Young Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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