1
|
Kadowaki M, Sugiyama K, Nozaki T, Yamasaki T, Namba H, Shimizu M, Kurozumi K. Scalp Nerve Block Alleviates Headaches Associated With Sonication During Transcranial Magnetic Resonance-Guided Focused Ultrasound. Neurosurgery 2024; 95:447-455. [PMID: 38687082 DOI: 10.1227/neu.0000000000002962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/01/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In magnetic resonance-guided focused ultrasound (MRgFUS) procedures, headache is a frequent symptom and cause of treatment discontinuation. Herein, we assessed the efficacy of scalp nerve block (SNB) for alleviating headache during MRgFUS procedures. METHODS The effect of SNB on intraprocedural headache was examined by retrospectively comparing 2 patient cohorts at a single institution. During the study period from April 2020 to February 2022, an SNB protocol for all patients with a skull density ratio ≤0.55 was instituted on October 6, 2021. The number of patients with a skull density ratio ≤0.55 was 34 before the protocol and 36 afterward. Headache intensity was evaluated using a numerical rating scale (NRS) after each sonication. To evaluate the effect of SNB on headache intensity, multiple regression analysis was performed per patient and per sonication. In the per-patient analysis, the effect of SNB was evaluated using the maximum NRS, mean NRS, and NRS at the first ultrasound exposure that reached 52.5°C. In the per-sonication analysis, the effect of SNB was evaluated not only for the entire sonication but also for sonications classified into ≤9999 J, 10 000 to 29 999 J, and ≥30 000 J energy doses. RESULTS With SNB, headache alleviation was observed in the NRS after the first sonication that reached 52.5°C in each patient (β = -2.40, 95% CI -4.05 to -0.758, P = .00499), in the NRS when all sonications were evaluated (β = -0.647, 95% CI -1.19 to -0.106, P = .0201), and in the NRS when all sonications were classified into 10 000 to 29 999 J (β = -1.83, 95% CI -3.17 to -0.485, P = .00889). CONCLUSION SNB significantly reduced headache intensity during MRgFUS, especially that caused by sonication with a moderate-energy dose. These findings suggest that scalp nerves play a role in headache mechanisms during MRgFUS.
Collapse
Affiliation(s)
- Makoto Kadowaki
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu , Shizuoka , Japan
| | - Kenji Sugiyama
- Department of Neurosurgery, Toyoda Eisei Hospital, Iwata , Shizuoka , Japan
| | - Takao Nozaki
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu , Shizuoka , Japan
| | - Tomohiro Yamasaki
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu , Shizuoka , Japan
| | - Hiroki Namba
- Department of Neurosurgery, JA Shizuoka Kohseiren Enshu Hospital, Hamamatsu , Shizuoka , Japan
| | - Mikihiro Shimizu
- Center for Clinical Research, Hamamatsu University Hospital, Hamamatsu , Shizuoka , Japan
| | - Kazuhiko Kurozumi
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu , Shizuoka , Japan
| |
Collapse
|
2
|
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] [MESH Headings] [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.
Collapse
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
| |
Collapse
|
3
|
Legon W, Strohman A, In A, Payne B. Noninvasive neuromodulation of subregions of the human insula differentially affect pain processing and heart-rate variability: a within-subjects pseudo-randomized trial. Pain 2024; 165:1625-1641. [PMID: 38314779 PMCID: PMC11189760 DOI: 10.1097/j.pain.0000000000003171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 02/07/2024]
Abstract
ABSTRACT The insula is an intriguing target for pain modulation. Unfortunately, it lies deep to the cortex making spatially specific noninvasive access difficult. Here, we leverage the high spatial resolution and deep penetration depth of low-intensity focused ultrasound (LIFU) to nonsurgically modulate the anterior insula (AI) or posterior insula (PI) in humans for effect on subjective pain ratings, electroencephalographic (EEG) contact heat-evoked potentials, as well as autonomic measures including heart-rate variability (HRV). In a within-subjects, repeated-measures, pseudo-randomized trial design, 23 healthy volunteers received brief noxious heat pain stimuli to the dorsum of their right hand during continuous heart-rate, electrodermal, electrocardiography and EEG recording. Low-intensity focused ultrasound was delivered to the AI (anterior short gyrus), PI (posterior longus gyrus), or under an inert Sham condition. The primary outcome measure was pain rating. Low-intensity focused ultrasound to both AI and PI similarly reduced pain ratings but had differential effects on EEG activity. Low-intensity focused ultrasound to PI affected earlier EEG amplitudes, whereas LIFU to AI affected later EEG amplitudes. Only LIFU to the AI affected HRV as indexed by an increase in SD of N-N intervals and mean HRV low-frequency power. Taken together, LIFU is an effective noninvasive method to individually target subregions of the insula in humans for site-specific effects on brain biomarkers of pain processing and autonomic reactivity that translates to reduced perceived pain to a transient heat stimulus.
Collapse
Affiliation(s)
- Wynn Legon
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, United States
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
- Center for Human Neuroscience Research, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, United States
- Center for Health Behaviors Research, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, United States
| | - Andrew Strohman
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Graduate Program in Translational Biology, Medicine, and Health, Virginia Polytechnic Institute and State University, Roanoke, VA, United States
| | - Alexander In
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
| | - Brighton Payne
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, United States
- Center for Health Behaviors Research, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, United States
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Ng PR, Blitz SE, Chua MMJ, Cosgrove GR. Magnetic resonance-guided focused ultrasound thalamotomy for essential tremor patients with low skull density ratio: a case-matched analysis. Front Neurol 2024; 15:1370574. [PMID: 38711556 PMCID: PMC11071343 DOI: 10.3389/fneur.2024.1370574] [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: 01/15/2024] [Accepted: 04/04/2024] [Indexed: 05/08/2024] Open
Abstract
Introduction Skull density ratio (SDR) is the ratio between the mean Hounsfield units of marrow and cortical bone, impacting energy transmission through the skull. Low SDR has been used as an exclusion criterion in major trials of magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for medication-refractory essential tremor (ET). However, some studies have suggested that patients with low SDR can safely undergo MRgFUS with favorable outcomes. In this case-matched study, we aim to compare the characteristics, sonication parameters, lesion sizes, and clinical outcomes of patients with low SDR vs. patients with high SDR who underwent unilateral MRgFUS thalamotomy for medication-refractory ET. Methods Between March 2016 and April 2023, all patients (n = 270) who underwent unilateral MRgFUS thalamotomy for medication-refractory ET at a single institution were classified as low SDR (<0.40) and high SDR (≥0.40). All clinical and radiological data was prospectively collected and retrospectively analyzed using non-case-matched and 1:1 case-matched methodology. Results Thirty-one patients had low SDR, and 239 patients had high SDR. Fifty-six patients (28 in each cohort) were included in 1:1 case-matched analysis. There were no significant differences in baseline characteristics between the two groups in both non-case-matched and 1:1 case-matched analyses. In both analyses, compared to patients with high SDR, patients with low SDR required a significantly higher maximum sonication power, energy, and duration, and reached a lower maximum temperature with smaller lesion volumes. In the non-case-matched and case-matched analyses, low SDR patients did not have significantly less tremor control at any postoperative timepoints. However, there was a higher chance of procedure failure in the low SDR group with three patients not obtaining an appropriately sized lesion. In both analyses, imbalance was observed more often in high SDR patients on postoperative day 1 and month 3. Discussion ET patients with SDR <0.40 can be safely and effectively treated with MRgFUS, though there may be higher rates of treatment failure and intraoperative discomfort.
Collapse
Affiliation(s)
- Patrick R. Ng
- Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States
| | | | - Melissa M. J. Chua
- Harvard Medical School, Boston, CA, United States
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - G. Rees Cosgrove
- Harvard Medical School, Boston, CA, United States
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, United States
| |
Collapse
|
7
|
Hashida M, Maesawa S, Kato S, Nakatsubo D, Tsugawa T, Torii J, Tanei T, Ishizaki T, Mutoh M, Ito Y, Tsuboi T, Mizuno S, Suzuki M, Wakabayashi T, Katsuno M, Saito R. Outcomes and Prognostic Factors of Magnetic Resonance-guided Focused Ultrasound Thalamotomy for Essential Tremor at 2-year Follow-up. Neurol Med Chir (Tokyo) 2024; 64:137-146. [PMID: 38355128 PMCID: PMC11099165 DOI: 10.2176/jns-nmc.2023-0202] [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: 08/27/2023] [Accepted: 12/11/2023] [Indexed: 02/16/2024] Open
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is an effective treatment for essential tremor (ET). However, its long-term outcomes and prognostic factors remain unclear. This study aimed to retrospectively investigate 38 patients with ET who underwent MRgFUS thalamotomy and were followed up for >2 years. The improvement in tremor was evaluated using the Clinical Rating Scale for Tremor (CRST). Adverse events were documented, and correlations with factors, such as skull density ratio (SDR), maximum mean temperature (T-max), and lesion size, were examined. Furthermore, the outcomes were compared between two groups, one that met the cutoff values, which was previously reported (preoperative CRST-B ≤ 25, T-max ≥ 52.5°C, anterior-posterior size of lesion ≥ 3.9 mm, superior-inferior [SI] size of lesion > 5.5 mm), and the other that did not. The improvement rate was 59.4% on average at the 2-year follow-up. Adverse events, such as numbness (15.8%), dysarthria (10.5%), and lower extremity weakness (2.6%), were observed even after 2 years, although these were mild. The factors correlated with tremor improvement were the T-max and SI size of the lesion (p < 0.05), whereas the SDR showed no significance. Patients who met the aforementioned cutoff values demonstrated a 69.8% improvement at the 2-year follow-up, whereas others showed a 43.6% improvement (p < 0.05). In conclusion, MRgFUS is effective even after 2 years. The higher the T-max and the larger the lesion size, the better the tremor control. Previously reported cutoff values clearly predict the 2-year prognosis, indicating the usefulness of MRgFUS.
Collapse
Affiliation(s)
- Miki Hashida
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Satoshi Maesawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Brain and Mind Research Center, Nagoya University
| | - Sachiko Kato
- Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | | | | | - Jun Torii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Takafumi Tanei
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Tomotaka Ishizaki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Manabu Mutoh
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Yoshiki Ito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Takashi Tsuboi
- Department of Neurology, Nagoya University Graduate School of Medicine
| | - Satomi Mizuno
- Department of Rehabilitation Medicine, National Hospital Organization, Nagoya Medical Center
| | - Masashi Suzuki
- Department of Neurology, Nagoya University Graduate School of Medicine
- Department of Clinical Laboratory, Nagoya University Hospital
| | | | - Masahisa Katsuno
- Brain and Mind Research Center, Nagoya University
- Department of Neurology, Nagoya University Graduate School of Medicine
- Department of Clinical Research Education, Nagoya University Graduate School of Medicine
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Brain and Mind Research Center, Nagoya University
| |
Collapse
|
8
|
Ahmed AK, Zhuo J, Gullapalli RP, Jiang L, Keaser ML, Greenspan JD, Chen C, Miller TR, Melhem ER, Sansur CA, Eisenberg HM, Gandhi D. Focused Ultrasound Central Lateral Thalamotomy for the Treatment of Refractory Neuropathic Pain: Phase I Trial. Neurosurgery 2024; 94:690-699. [PMID: 37947407 DOI: 10.1227/neu.0000000000002752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/19/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Magnetic resonance-guided focused ultrasound (MRgFUS) central lateral thalamotomy (CLT) has not yet been validated for treating refractory neuropathic pain (NP). Our aim was to assess the safety and potential efficacy of MRgFUS CLT for refractory NP. METHODS In this prospective, nonrandomized, single-arm, investigator-initiated phase I trial, patients with NP for more than 6 months related to phantom limb pain, spinal cord injury, or radiculopathy/radicular injury and who had undergone at least one previous failed intervention were eligible. The main outcomes were safety profile and pain as assessed using the brief pain inventory, the pain disability index, and the numeric rating scale. Medication use and the functional connectivity of the default mode network (DMN) were also assessed. RESULTS Ten patients were enrolled, with nine achieving successful ablation. There were no serious adverse events and 12 mild/moderate severity events. The mean age was 50.9 years (SD: 12.7), and the mean symptom duration was 12.3 years (SD: 9.7). Among eight patients with a 1-year follow-up, the brief pain inventory decreased from 7.6 (SD: 1.1) to 3.8 (SD: 2.8), with a mean percent decrease of 46.3 (SD: 40.6) (paired t -test, P = .017). The mean pain disability index decreased from 43.0 (SD: 7.5) to 25.8 (SD: 16.8), with a mean percent decrease of 39.3 (SD: 41.6) ( P = .034). Numeric rating scale scores decreased from a mean of 7.2 (SD: 1.8) to 4.0 (SD: 2.8), with a mean percent decrease of 42.8 (SD: 37.8) ( P = .024). Patients with predominantly intermittent pain or with allodynia responded better than patients with continuous pain or without allodynia, respectively. Some patients decreased medication use. Resting-state functional connectivity changes were noted, from disruption of the DMN at baseline to reactivation of connectivity between DMN nodes at 3 months. CONCLUSION MRgFUS CLT is feasible and safe for refractory NP and has potential utility in reducing symptoms as measured by validated pain scales.
Collapse
Affiliation(s)
- Abdul-Kareem Ahmed
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Jiachen Zhuo
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Rao P Gullapalli
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Li Jiang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Michael L Keaser
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore , Maryland , USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore , Maryland , USA
| | - Joel D Greenspan
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore , Maryland , USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore , Maryland , USA
| | - Chixiang Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore , Maryland , USA
- Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Timothy R Miller
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Elias R Melhem
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Charles A Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Howard M Eisenberg
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore , Maryland , USA
| | - Dheeraj Gandhi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore , Maryland , USA
| |
Collapse
|
9
|
Marchant JK, Clinard SR, Odéen H, Parker DL, Christensen DA. The influence of bone model geometries on the determination of skull acoustic properties. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3779. [PMID: 37794748 PMCID: PMC10841890 DOI: 10.1002/cnm.3779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/06/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
In this study, we investigated the impact of various simulated skull bone geometries on the determination of skull speed of sound and acoustic attenuation values via optimization using transmitted pressure amplitudes beyond the bone. Using the hybrid angular spectrum method (HAS), we simulated ultrasound transmission through four model sets of different geometries involving sandwiched layers of diploë and cortical bone in addition to three models generated from CT images of ex-vivo human skull-bones. We characterized cost-function solution spaces for each model and, using optimization, found that when a model possessed appreciable variations in resolvable layer thickness, the predefined attenuation coefficients could be found with low error (RMSE < 0.01 Np/cm). However, we identified a spatial frequency cutoff in the models' geometry beyond which the accuracy of the property determination begins to fail, depending on the frequency of the ultrasound source. There was a large increase in error of the attenuation coefficients determined by the optimization when the variations in layer thickness were above the identified spatial frequency cutoffs, or when the lateral variations across the model were relatively low in amplitude. For our limited sample of three CT-image derived bone models, the attenuation coefficients were determined successfully. The speed of sound values were determined with low error for all models (including the CT-image derived models) that were tested (RMSE < 0.4 m/s). These results illustrate that it is possible to determine the acoustic properties of two-component models when the internal bone structure is taken into account and the structure satisfies the spatial frequency constraints discussed.
Collapse
Affiliation(s)
- Joshua K. Marchant
- Department of Physics and Astronomy, University of Utah, Salt Lake City, UT, USA
| | - Samuel R. Clinard
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Henrik Odéen
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Dennis L. Parker
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Douglas A. Christensen
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
10
|
Kaburagi M, Maki F, Hino S, Nakano M, Yamaguchi T, Takasaki M, Iwamuro H, Iijima K, Sasanuma J, Watanabe K, Hasegawa Y, Yamano Y. Video Motion Analysis as a Quantitative Evaluation Tool for Essential Tremor during Magnetic Resonance-Guided Focused Ultrasound Thalamotomy. Neurol Int 2023; 15:1411-1422. [PMID: 38132970 PMCID: PMC10745303 DOI: 10.3390/neurolint15040091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
The Clinical Rating Scale for Tremor (CRST) is commonly used to evaluate essential tremor (ET) during focused ultrasound (FUS) thalamotomy. However, it faces challenges such as the ceiling effect and test-retest variability. This study explored the utility of videographic motion analysis as an evaluation index for ET. Forty-three patients with ET performed postural tremor and line-drawing tasks recorded on video, and the data were analyzed using motion analysis software. The test-retest and inter-rater reliability, correlations with the CRST and tremor scores, and pre/post-FUS treatment comparisons were analyzed. The video motion analysis showed excellent test-retest and inter-rater reliability. In the postural tremor tasks, video parameter amplitude significantly correlated with the CRST and tremor scores. Similarly, for the line-drawing task, video parameter amplitude showed significant correlations with CRST and tremor scores, effectively addressing the ceiling effect. Regarding post-FUS treatment improvements, changes in the CRST and tremor scores were significantly associated with changes in video parameter amplitude. In conclusion, quantitative analysis of the video motion of ET enables precise evaluation of kinematic characteristics and effectively resolves the ceiling effect and test-retest variability. The video motion analysis score accurately reflected the tremor severity and treatment effects, demonstrating its high clinical utility.
Collapse
Affiliation(s)
- Mayumi Kaburagi
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan; (M.K.); (F.M.); (Y.H.)
- Department of Neurology, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan
| | - Futaba Maki
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan; (M.K.); (F.M.); (Y.H.)
- Department of Neurology, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan
| | - Sakae Hino
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan; (M.K.); (F.M.); (Y.H.)
- Department of Neurology, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan
| | - Masayuki Nakano
- Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan; (M.N.)
| | - Toshio Yamaguchi
- Research Institute for Diagnostic Radiology, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan
- International Academia for Focused Ultrasound Therapy, Kanagawa 215-0023, Japan
| | - Masahito Takasaki
- Department of Anesthesiology, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan
| | - Hirokazu Iwamuro
- Department of Neurosurgery, Juntendo University, Tokyo 113-8421, Japan
| | - Ken Iijima
- Department of Diagnostic Radiology, Saitama Sekishinkai Hospital, Saitama 350-1305, Japan
| | - Jinichi Sasanuma
- Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan; (M.N.)
| | - Kazuo Watanabe
- Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan; (M.N.)
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan; (M.K.); (F.M.); (Y.H.)
- Department of Neurology, Shin-Yurigaoka General Hospital, Kanagawa 215-0026, Japan
| | - Yoshihisa Yamano
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan; (M.K.); (F.M.); (Y.H.)
| |
Collapse
|
11
|
Shin DH, Son S, Kim EY. Low-Energy Transcranial Navigation-Guided Focused Ultrasound for Neuropathic Pain: An Exploratory Study. Brain Sci 2023; 13:1433. [PMID: 37891801 PMCID: PMC10605299 DOI: 10.3390/brainsci13101433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Neuromodulation using high-energy focused ultrasound (FUS) has recently been developed for various neurological disorders, including tremors, epilepsy, and neuropathic pain. We investigated the safety and efficacy of low-energy FUS for patients with chronic neuropathic pain. We conducted a prospective single-arm trial with 3-month follow-up using new transcranial, navigation-guided, focused ultrasound (tcNgFUS) technology to stimulate the anterior cingulate cortex. Eleven patients underwent FUS with a frequency of 250 kHz and spatial-peak temporal-average intensity of 0.72 W/cm2. A clinical survey based on the visual analog scale of pain and a brief pain inventory (BPI) was performed during the study period. The average age was 60.55 ± 13.18 years-old with a male-to-female ratio of 6:5. The median current pain decreased from 10.0 to 7.0 (p = 0.021), median average pain decreased from 8.5 to 6.0 (p = 0.027), and median maximum pain decreased from 10.0 to 8.0 (p = 0.008) at 4 weeks after treatment. Additionally, the sum of daily life interference based on BPI was improved from 59.00 ± 11.66 to 51.91 ± 9.18 (p = 0.021). There were no side effects such as burns, headaches, or seizures, and no significant changes in follow-up brain magnetic resonance imaging. Low-energy tcNgFUS could be a safe and noninvasive neuromodulation technique for the treatment of chronic neuropathic pain.
Collapse
Affiliation(s)
- Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| | - Seong Son
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| | - Eun Young Kim
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| |
Collapse
|
12
|
Blitz SE, Chua MMJ, Ng P, Segar DJ, Jha R, McDannold NJ, DeSalvo MN, Rolston JD, Cosgrove GR. Longitudinal MR imaging after unilateral MR-guided focused ultrasound thalamotomy: clinical and radiological correlation. Front Neurol 2023; 14:1272425. [PMID: 37869137 PMCID: PMC10587555 DOI: 10.3389/fneur.2023.1272425] [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: 08/04/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Magnetic-resonance-guided focused ultrasound (MRgFUS) thalamotomy uses multiple converging high-energy ultrasonic beams to produce thermal lesions in the thalamus. Early postoperative MR imaging demonstrates the location and extent of the lesion, but there is no consensus on the utility or frequency of postoperative imaging. We aimed to evaluate the evolution of MRgFUS lesions and describe the incidence, predictors, and clinical effects of lesion persistence in a large patient cohort. Methods A total of 215 unilateral MRgFUS thalamotomy procedures for essential tremor (ET) by a single surgeon were retrospectively analyzed. All patients had MR imaging 1 day postoperatively; 106 had imaging at 3 months and 32 had imaging at 1 year. Thin cut (2 mm) axial and coronal T2-weighted MRIs at these timepoints were analyzed visually on a binary scale for lesion presence and when visible, lesion volumes were measured. SWI and DWI sequences were also analyzed when available. Clinical outcomes including tremor scores and side effects were recorded at these same time points. We analyzed if patient characteristics (age, skull density ratio), preoperative tremor score, and sonication parameters influenced lesion evolution and if imaging characteristics correlated with clinical outcomes. Results Visible lesions were present in all patients 1 day post- MRgFUS and measured 307.4 ± 128.7 mm3. At 3 months, residual lesions (excluding patients where lesions were not visible) were 83.6% smaller and detectable in only 54.7% of patients (n = 58). At 1 year, residual lesions were detected in 50.0% of patients (n = 16) and were 90.7% smaller than 24 h and 46.5% smaller than 3 months. Lesions were more frequently visible on SWI (100%, n = 17), DWI (n = 38, 97.4%) and ADC (n = 36, 92.3%). At 3 months, fewer treatment sonications, higher maximum power, and greater distance between individual sonications led to larger lesion volumes. Volume at 24 h did not predict if a lesion was visible later. Lesion visibility at 3 months predicted sensory side effects but was not correlated with tremor outcomes. Discussion Overall, lesions are visible on T2-weighted MRI in about half of patients at both 3 months and 1 year post-MRgFUS thalamotomy. Certain sonication parameters significantly predicted persistent volume, but residual lesions did not correlate with tremor outcomes.
Collapse
Affiliation(s)
| | - Melissa M. J. Chua
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Patrick Ng
- Harvard Medical School, Boston, MA, United States
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - David J. Segar
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rohan Jha
- Harvard Medical School, Boston, MA, United States
| | - Nathan J. McDannold
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Matthew N. DeSalvo
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - John D. Rolston
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - G. Rees Cosgrove
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
13
|
Maragkos GA, Kosyakovsky J, Zhao P, Kearns KN, Rush-Evans S, Moosa S, Elias WJ. Patient-Reported Outcomes After Focused Ultrasound Thalamotomy for Tremor-Predominant Parkinson's Disease. Neurosurgery 2023; 93:884-891. [PMID: 37133259 DOI: 10.1227/neu.0000000000002518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 03/13/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) has emerged as a precise, incisionless approach to cerebral lesioning and an alternative to neuromodulation in movement disorders. Despite rigorous clinical trials, long-term patient-centered outcome data after MRgFUS for tremor-predominant Parkinson's Disease (TPPD) are relatively lacking. OBJECTIVE To report long-term data on patient satisfaction and quality of life after MRgFUS thalamotomy for TPPD. METHODS In a retrospective study of patients who underwent MRgFUS thalamotomy for TPPD at our institution between 2015 and 2022, a patient survey was administered to collect self-reported measures of tremor improvement, recurrence, Patients' Global Impression of Change (PGIC), and side effects. Patient demographics, FUS parameters, and lesion characteristics were analyzed. RESULTS A total of 29 patients were included with a median follow-up of 16 months. Immediate tremor improvement was achieved in 96% of patients. Sustained improvement was achieved in 63% of patients at last follow-up. Complete tremor recurrence to baseline occurred for 17% of patients. Life quality improvement denoted by a PGIC of 1 to 2 was reported by 69% of patients. Long-term side effects were reported by 38% of patients and were mostly mild. Performing a secondary anteromedial lesion to target the ventralis oralis anterior/posterior nucleus was associated with higher rates of speech-related side effects (56% vs 12%), without significant improvement in tremor outcomes. CONCLUSION Patient satisfaction with FUS thalamotomy for tremor-predominant PD was very high, even at longer term. Extended lesioning to target the motor thalamus did not improve tremor control and may contribute to greater frequency of postoperative motor- and speech-related side effects.
Collapse
Affiliation(s)
- Georgios A Maragkos
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Jacob Kosyakovsky
- University of Virginia School of Medicine, Charlottesville , Virginia , USA
| | - Patricia Zhao
- University of Virginia School of Medicine, Charlottesville , Virginia , USA
| | - Kathryn N Kearns
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Shelly Rush-Evans
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Shayan Moosa
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - W Jeffrey Elias
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| |
Collapse
|
14
|
Caston RM, Campbell JM, Rahimpour S, Moretti P, Alexander MD, Rolston JD. Hemorrhagic Safety of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Tremor without Interruption of Antiplatelet or Anticoagulant Therapy. Stereotact Funct Neurosurg 2023; 101:314-318. [PMID: 37690446 PMCID: PMC10591802 DOI: 10.1159/000533590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is an incision-less ablative technique used to treat medically refractory tremor. Although intracerebral hemorrhage has not been reported with MRgFUS thalamotomy for the treatment of movement disorders, clinicians commonly interrupt active blood thinning medications prior to the procedure or offer gamma knife radiosurgery instead. However, MRgFUS uses focal thermoablation, and bleeding risk is likely minimal. This study aimed to evaluate the safety of MRgFUS thalamotomy in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) without interrupting anticoagulant or antiplatelet therapies. METHODS This was a single-center retrospective case series of all patients with ET or PD undergoing MRgFUS from February 2019 through December 2022 (n = 96). Demographic variables and medications taken at the time of surgery were obtained. Our primary outcome was the type and frequency of hemorrhagic complications noted on the operative report or postoperative imaging. RESULTS The mean age of patients was 74.2 years, and 26% were female. Forty patients were taking ≥1 antiplatelet or anticoagulant medications. No patient actively taking anticoagulant or antiplatelet therapies had a hemorrhagic complication during or <48 h after the procedure. CONCLUSION The frequency of intra- or postoperative complications from MRgFUS was not higher in patients actively taking anticoagulant or antiplatelet therapies relative to those who were not. Our findings suggest that MRgFUS thalamotomy does not necessitate interrupting anticoagulant or antiplatelet therapies. However, given the limited number of patients actively taking these therapies in our cohort (n = 40), additional testing in large, prospective studies should be conducted to further establish safety.
Collapse
Affiliation(s)
- Rose M Caston
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Justin M Campbell
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
- Interdepartmental Program in Neuroscience, University of Utah, Salt Lake City, Utah, USA
| | - Shervin Rahimpour
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Paolo Moretti
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
- George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Matthew D Alexander
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah, USA
| | - John D Rolston
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
15
|
Liu H, Sigona MK, Manuel TJ, Chen LM, Dawant BM, Caskey CF. Evaluation of synthetically generated computed tomography for use in transcranial focused ultrasound procedures. J Med Imaging (Bellingham) 2023; 10:055001. [PMID: 37744953 PMCID: PMC10514703 DOI: 10.1117/1.jmi.10.5.055001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 07/06/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Purpose Transcranial focused ultrasound (tFUS) is a therapeutic ultrasound method that focuses sound through the skull to a small region noninvasively and often under magnetic resonance imaging (MRI) guidance. CT imaging is used to estimate the acoustic properties that vary between individual skulls to enable effective focusing during tFUS procedures, exposing patients to potentially harmful radiation. A method to estimate acoustic parameters in the skull without the need for CT is desirable. Approach We synthesized CT images from routinely acquired T1-weighted MRI using a 3D patch-based conditional generative adversarial network and evaluated the performance of synthesized CT (sCT) images for treatment planning with tFUS. We compared the performance of sCT with real CT (rCT) images for tFUS planning using Kranion and simulations using the acoustic toolbox, k-Wave. Simulations were performed for 3 tFUS scenarios: (1) no aberration correction, (2) correction with phases calculated from Kranion, and (3) phase shifts calculated from time reversal. Results From Kranion, the skull density ratio, skull thickness, and number of active elements between rCT and sCT had Pearson's correlation coefficients of 0.94, 0.92, and 0.98, respectively. Among 20 targets, differences in simulated peak pressure between rCT and sCT were largest without phase correction (12.4 % ± 8.1 % ) and smallest with Kranion phases (7.3 % ± 6.0 % ). The distance between peak focal locations between rCT and sCT was < 1.3 mm for all simulation cases. Conclusions Real and synthetically generated skulls had comparable image similarity, skull measurements, and acoustic simulation metrics. Our work demonstrated similar results for 10 testing cases comparing MR-sCTs and rCTs for tFUS planning. Source code and a docker image with the trained model are available at https://github.com/han-liu/SynCT_TcMRgFUS.
Collapse
Affiliation(s)
- Han Liu
- Vanderbilt University, Department of Computer Science, Nashville, Tennessee, United States
| | - Michelle K. Sigona
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt University, Institute of Imaging Science, Nashville, Tennessee, United States
| | - Thomas J. Manuel
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt University, Institute of Imaging Science, Nashville, Tennessee, United States
| | - Li Min Chen
- Vanderbilt University, Institute of Imaging Science, Nashville, Tennessee, United States
- Vanderbilt University, Department of Radiology and Radiological Sciences, Nashville, Tennessee, United States
| | - Benoit M. Dawant
- Vanderbilt University, Department of Electrical and Computer Engineering, Nashville, Tennessee, United States
| | - Charles F. Caskey
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt University, Institute of Imaging Science, Nashville, Tennessee, United States
- Vanderbilt University, Department of Radiology and Radiological Sciences, Nashville, Tennessee, United States
| |
Collapse
|
16
|
He X, Oshino S, Hosomi K, Kanemoto M, Tani N, Kishima H. Characteristics of Pain During MRI-Guided Focused Ultrasound Thalamotomy. Neurosurgery 2023; 93:358-365. [PMID: 36861986 PMCID: PMC10319367 DOI: 10.1227/neu.0000000000002420] [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: 08/25/2022] [Accepted: 12/22/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Magnetic resonance imaging-guided focused ultrasound (MRgFUS) has become popular as an incisionless mode of neurosurgical treatment. However, head pain during sonication is common and its pathophysiology remains poorly understood. OBJECTIVE To explore the characteristics of head pain occurring during MRgFUS thalamotomy. METHODS Our study comprised 59 patients who answered questions about the pain they experienced during unilateral MRgFUS thalamotomy. The location and features of pain were investigated using a questionnaire including the numerical rating scale (NRS) to estimate maximum pain intensity and the Japanese version of the Short Form of McGill Pain Questionnaire 2 to evaluate the quantitative and qualitative dimensions of pain. Several clinical factors were investigated for possible correlation with pain intensity. RESULTS Forty-eight patients (81%) reported sonication-related head pain, and the degree of pain was severe (NRS score ≥ 7) in 39 patients (66%). The distribution of sonication-related pain was "localized" in 29 (49%) and "diffuse" in 16 (27%); the most frequent location was the "occipital" region. The pain features most frequently reported were those in the "affective" subscale of the Short Form of McGill Pain Questionnaire 2. Patients with diffuse pain had a higher NRS score and lower skull density ratio than did patients with localized pain. The NRS score negatively correlated with tremor improvement at 6 months post-treatment. CONCLUSION Most patients in our cohort experienced pain during MRgFUS. The distribution and intensity of pain varied according to the skull density ratio, indicating that the pain might have had different origins. Our results may contribute to the improvement of pain management during MRgFUS.
Collapse
Affiliation(s)
- Xin He
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Satoru Oshino
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Hosomi
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Manabu Kanemoto
- Department of Neurosurgery, Saito Yukoukai Hospital, Ibaraki, Osaka, Japan
| | - Naoki Tani
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| |
Collapse
|
17
|
Hughes A, Khan DS, Alkins R. Current and Emerging Systems for Focused Ultrasound-Mediated Blood-Brain Barrier Opening. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1479-1490. [PMID: 37100672 DOI: 10.1016/j.ultrasmedbio.2023.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/09/2023] [Accepted: 02/23/2023] [Indexed: 05/17/2023]
Abstract
With an ever-growing list of neurological applications of focused ultrasound (FUS), there has been a consequent increase in the variety of systems for delivering ultrasound energy to the brain. Specifically, recent successful pilot clinical trials of blood-brain barrier (BBB) opening with FUS have generated substantial interest in the future applications of this relatively novel therapy, with divergent, purpose-built technologies emerging. With many of these technologies at various stages of pre-clinical and clinical investigation, this article seeks to provide an overview and analysis of the numerous medical devices in active use and under development for FUS-mediated BBB opening.
Collapse
Affiliation(s)
- Alec Hughes
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Dure S Khan
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Ryan Alkins
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada; Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada.
| |
Collapse
|
18
|
Legon W, Strohman A, In A, Stebbins K, Payne B. Non-invasive neuromodulation of sub-regions of the human insula differentially affect pain processing and heart-rate variability. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.05.539593. [PMID: 37205396 PMCID: PMC10187309 DOI: 10.1101/2023.05.05.539593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The insula is a portion of the cerebral cortex folded deep within the lateral sulcus covered by the overlying opercula of the inferior frontal lobe and superior portion of the temporal lobe. The insula has been parsed into sub-regions based upon cytoarchitectonics and structural and functional connectivity with multiple lines of evidence supporting specific roles for each of these sub-regions in pain processing and interoception. In the past, causal interrogation of the insula was only possible in patients with surgically implanted electrodes. Here, we leverage the high spatial resolution combined with the deep penetration depth of low-intensity focused ultrasound (LIFU) to non-surgically modulate either the anterior insula (AI) or posterior insula (PI) in humans for effect on subjective pain ratings, electroencephalographic (EEG) contact head evoked potentials (CHEPs) and time-frequency power as well as autonomic measures including heart-rate variability (HRV) and electrodermal response (EDR). N = 23 healthy volunteers received brief noxious heat pain stimuli to the dorsum of their right hand during continuous heart-rate, EDR and EEG recording. LIFU was delivered to either the AI (anterior short gyrus), PI (posterior longus gyrus) or under an inert sham condition time-locked to the heat stimulus. Results demonstrate that single-element 500 kHz LIFU is capable of individually targeting specific gyri of the insula. LIFU to both AI and PI similarly reduced perceived pain ratings but had differential effects on EEG activity. LIFU to PI affected earlier EEG amplitudes around 300 milliseconds whereas LIFU to AI affected EEG amplitudes around 500 milliseconds. In addition, only LIFU to the AI affected HRV as indexed by an increase in standard deviation of N-N intervals (SDNN) and mean HRV low frequency power. There was no effect of LIFU to either AI or PI on EDR or blood pressure. Taken together, LIFU looks to be an effective method to individually target sub-regions of the insula in humans for site-specific effects on brain biomarkers of pain processing and autonomic reactivity that translates to reduced perceived pain to a transient heat stimulus. These data have implications for the treatment of chronic pain and several neuropsychological diseases like anxiety, depression and addiction that all demonstrate abnormal activity in the insula concomitant with dysregulated autonomic function.
Collapse
Affiliation(s)
- Wynn Legon
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, 24016, USA
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA
- Center for Human Neuroscience Research, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, 24016, USA
- Center for Health Behaviors Research, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, 24016, USA
| | - Andrew Strohman
- Virginia Tech Carilion School of Medicine, Roanoke, VA, 24016, USA
- Graduate Program in Translational Biology, Medicine, and Health, Virginia Polytechnic Institute and State University, Roanoke, VA, 24016, USA
| | - Alexander In
- Virginia Tech Carilion School of Medicine, Roanoke, VA, 24016, USA
| | - Katelyn Stebbins
- Virginia Tech Carilion School of Medicine, Roanoke, VA, 24016, USA
- Graduate Program in Translational Biology, Medicine, and Health, Virginia Polytechnic Institute and State University, Roanoke, VA, 24016, USA
| | - Brighton Payne
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, 24016, USA
- Center for Health Behaviors Research, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, 24016, USA
| |
Collapse
|
19
|
Kyle K, Maller J, Barnett Y, Jonker B, Barnett M, D’Souza A, Calamante F, Maamary J, Peters J, Wang C, Tisch S. Tremor suppression following treatment with MRgFUS: skull density ratio consistency and degree of posterior dentatorubrothalamic tract lesioning predicts long-term clinical outcomes in essential tremor. Front Neurol 2023; 14:1129430. [PMID: 37181561 PMCID: PMC10166854 DOI: 10.3389/fneur.2023.1129430] [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: 12/22/2022] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives Magnetic resonance-guided focussed ultrasound (MRgFUS) is an incisionless ablative procedure, widely used for treatment of Parkinsonian and Essential Tremor (ET). Enhanced understanding of the patient- and treatment-specific factors that influence sustained long-term tremor suppression could help clinicians achieve superior outcomes via improved patient screening and treatment strategy. Methods We retrospectively analysed data from 31 subjects with ET, treated with MRgFUS at a single centre. Tremor severity was assessed with parts A, B and C of the Clinical Rating Scale for Tremor (CRST) as well as the combined CRST. Tremor in the dominant and non-dominant hand was assessed with Hand Tremor Scores (HTS), derived from the CRST. Pre- and post-treatment imaging data were analysed to determine ablation volume overlap with automated thalamic segmentations, and the dentatorubrothalamic tract (DRTT) and compared with percentage change in CRST and HTS following treatment. Results Tremor symptoms were significantly reduced following treatment. Combined pre-treatment CRST (mean: 60.7 ± 17.3) and HTS (mean: 19.2 ± 5.7) improved by an average of 45.5 and 62.6%, respectively. Percentage change in CRST was found to be significantly negatively associated with age (β = -0.375, p = 0.015), and SDR standard deviation (SDRSD; β = -0.324, p = 0.006), and positively associated with ablation overlap with the posterior DRTT (β = 0.535, p < 0.001). Percentage HTS improvement in the dominant hand decreased significantly with older age (β = -0.576, p < 0.01). Conclusion Our results suggest that increased lesioning of the posterior region of the DRTT could result in greater improvements in combined CRST and non-dominant hand HTS, and that subjects with lower SDR standard deviation tended to experience greater improvement in combined CRST.
Collapse
Affiliation(s)
- Kain Kyle
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
| | | | - Yael Barnett
- Department of Medical Imaging, and Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Benjamin Jonker
- Department of Neurosurgery, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Royal Prince Alfred Institute of Academic Surgery, University of Sydney, Camperdown, NSW, Australia
| | - Michael Barnett
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Arkiev D’Souza
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | - Fernando Calamante
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW, Australia
- Sydney Imaging, The University of Sydney, Sydney, NSW, Australia
| | - Joel Maamary
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - James Peters
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Chenyu Wang
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
| | - Stephen Tisch
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
20
|
Yuen J, Goyal A, Kaufmann TJ, Jackson LM, Miller KJ, Klassen BT, Dhawan N, Lee KH, Lehman VT. Comparison of the impact of skull density ratio with alternative skull metrics on magnetic resonance-guided focused ultrasound thalamotomy for tremor. J Neurosurg 2023; 138:50-57. [PMID: 35901729 DOI: 10.3171/2022.5.jns22350] [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: 02/10/2022] [Accepted: 05/12/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE One of the key metrics that is used to predict the likelihood of success of MR-guided focused ultrasound (MRgFUS) thalamotomy is the overall calvarial skull density ratio (SDR). However, this measure does not fully predict the sonication parameters that would be required or the technical success rates. The authors aimed to assess other skull characteristics that may also contribute to technical success. METHODS The authors retrospectively studied consecutive patients with essential tremor who were treated by MRgFUS at their center between 2017 and 2021. They evaluated the correlation between the different treatment parameters, particularly maximum power and energy delivered, with a range of patients' skull metrics and demographics. Machine learning algorithms were applied to investigate whether sonication parameters could be predicted from skull density metrics alone and whether including combined local transducer SDRs with overall calvarial SDR would increase model accuracy. RESULTS A total of 62 patients were included in the study. The mean age was 77.1 (SD 9.2) years, and 78% of treatments (49/63) were performed in males. The mean SDR was 0.51 (SD 0.10). Among the evaluated metrics, SDR had the highest correlation with the maximum power used in treatment (ρ = -0.626, p < 0.001; proportion of local SDR values ≤ 0.8 group also had ρ = +0.626, p < 0.001) and maximum energy delivered (ρ = -0.680, p < 0.001). Machine learning algorithms achieved a moderate ability to predict maximum power and energy required from the local and overall SDRs (accuracy of approximately 80% for maximum power and approximately 55% for maximum energy), and high ability to predict average maximum temperature reached from the local and overall SDRs (approximately 95% accuracy). CONCLUSIONS The authors compared a number of skull metrics against SDR and showed that SDR was one of the best indicators of treatment parameters when used alone. In addition, a number of other machine learning algorithms are proposed that may be explored to improve its accuracy when additional data are obtained. Additional metrics related to eventual sonication parameters should also be identified and explored.
Collapse
Affiliation(s)
- Jason Yuen
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Abhinav Goyal
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kai J Miller
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kendall H Lee
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Vance T Lehman
- 4Department of Radiology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Phipps MA, Jonathan S, Yang PF, Chen LM, Grissom W, Caskey CF. A reduced aperture allows for transcranial focus localization at lower pressure. JASA EXPRESS LETTERS 2022; 2:062001. [PMID: 35782333 PMCID: PMC9245740 DOI: 10.1121/10.0011695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
Localizing the focus during transcranial focused ultrasound procedures is important to ensure accurate targeting of specific brain regions and interpretation of results. Magnetic resonance acoustic radiation force imaging uses the displacement induced by the ultrasound focus in the brain to localize the beam, but the high pressure required to displace brain tissue may cause damage or confounds during subsequent neuromodulatory experiments. Here, reduced apertures were applied to a phased array transducer to generate comparable displacement to the full aperture but with 20% lower free field pressure.
Collapse
Affiliation(s)
- M Anthony Phipps
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - Sumeeth Jonathan
- Biomedical Engineering, Vanderbilt University, Nashville, Tennessee 37232, USA , , , , ,
| | - Pai-Feng Yang
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - Li Min Chen
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - William Grissom
- Biomedical Engineering, Vanderbilt University, Nashville, Tennessee 37232, USA , , , , ,
| | - Charles F Caskey
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| |
Collapse
|
23
|
Baek H, Lockwood D, Mason EJ, Obusez E, Poturalski M, Rammo R, Nagel SJ, Jones SE. Clinical Intervention Using Focused Ultrasound (FUS) Stimulation of the Brain in Diverse Neurological Disorders. Front Neurol 2022; 13:880814. [PMID: 35614924 PMCID: PMC9124976 DOI: 10.3389/fneur.2022.880814] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Various surgical techniques and pharmaceutical treatments have been developed to improve the current technologies of treating brain diseases. Focused ultrasound (FUS) is a new brain stimulation modality that can exert a therapeutic effect on diseased brain cells, with this effect ranging from permanent ablation of the pathological neural circuit to transient excitatory/inhibitory modulation of the neural activity depending on the acoustic energy of choice. With the development of intraoperative imaging technology, FUS has become a clinically available noninvasive neurosurgical option with visual feedback. Over the past 10 years, FUS has shown enormous potential. It can deliver acoustic energy through the physical barrier of the brain and eliminate abnormal brain cells to treat patients with Parkinson's disease and essential tremor. In addition, FUS can help introduce potentially beneficial therapeutics at the exact brain region where they need to be, bypassing the brain's function barrier, which can be applied for a wide range of central nervous system disorders. In this review, we introduce the current FDA-approved clinical applications of FUS, ranging from thermal ablation to blood barrier opening, as well as the emerging applications of FUS in the context of pain control, epilepsy, and neuromodulation. We also discuss the expansion of future applications and challenges. Broadening FUS technologies requires a deep understanding of the effect of ultrasound when targeting various brain structures in diverse disease conditions in the context of skull interface, anatomical structure inside the brain, and pathology.
Collapse
Affiliation(s)
- Hongchae Baek
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Daniel Lockwood
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Emmanuel Obusez
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Stephen E. Jones
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- *Correspondence: Stephen E. Jones
| |
Collapse
|
24
|
Torii J, Maesawa S, Nakatsubo D, Tsugawa T, Kato S, Ishizaki T, Takai S, Shibata M, Wakabayashi T, Tsuboi T, Suzuki M, Saito R. Cutoff values for the best management strategy for magnetic resonance-guided focused ultrasound ablation for essential tremor. J Neurosurg 2022; 138:38-49. [PMID: 35993838 DOI: 10.3171/2022.3.jns212460] [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: 11/06/2022]
Abstract
OBJECTIVE The efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) ablation for essential tremor (ET) is well known; however, no prognostic factors have been established. The authors aimed to retrospectively investigate MRgFUS ablation outcomes and associated factors and to define the cutoff values for each prognostic factor. METHODS Sixty-four Japanese patients who underwent unilateral ventral intermediate nucleus thalamotomy with MRgFUS for ET were included. Follow-up evaluations were performed at 1 week and 1, 3, 6, 12, and 24 months postoperatively. Tremor suppression was evaluated using the Clinical Rating Scale for Tremor (CRST), and adverse effects were recorded postoperatively. Outcome-associated factors were examined preoperatively, intraoperatively, and postoperatively using multivariate analyses. The cutoff values for the prognostic factors were calculated using receiver operating characteristics. RESULTS Percentage improvements in the CRST scores of the affected upper limb were 82.4%, 72.2%, 68.6%, and 65.9% at 1, 3, 6, and 12 months, respectively. Preoperatively, a high skull density ratio (SDR) (p ≤ 0.047), low CRST part B score (used to assess tremors during several tasks) (cutoff value 25, p ≤ 0.041), and nonoccurrence of resting tremors (p = 0.027) were significantly associated with improved tremor control. An intraoperatively high maximum mean temperature (cutoff value 52.5°C, p ≤ 0.047), postoperatively large lesion (cutoff value 3.9 mm in the anterior-posterior direction, p ≤ 0.002; cutoff value 5.0-5.55 mm in the superior-inferior direction, p ≤ 0.026), and small transducer focus correction (p ≤ 0.015) were also associated with improved tremor control. No valid cutoff value was found for SDR. Adverse effects (limb weakness, sensory disturbance, ataxia/walking disturbance, dysgeusia, dysarthria, and facial swelling) occurred transiently and were associated with high SDR, high temperature, high number of sonication sessions, large lesion, and occurrence of resting tremor. Patients who developed leg weakness experienced greater percentage improvement in tremors at 3 months postoperatively than those who did not. CONCLUSIONS MRgFUS ablation could be used to achieve good tremor control with acceptable adverse effects in Japanese patients with ET. The relatively low SDR in Asian ethnic groups as compared with that of Western populations makes treatment difficult; however, the cutoff values obtained in this study may be useful for achieving good treatment outcomes even in such patients. Clinical trial registration no.: UMIN000026952 (University Hospital Medical Information Network). ABBREVIATIONS ACPC = anterior commissure-posterior commissure; AP = anterior to posterior; CRST = Clinical Rating Scale for Tremor; ET = essential tremor; MRgFUS = magnetic resonance-guided focused ultrasound; PC = posterior commissure; PSA = posterior subthalamic area; RL = right to left; ROC = receiver operating characteristic; SDR = skull density ratio; SI = superior to inferior; T2WI = T2-weighted imaging; VIM = ventral intermediate nucleus.
Collapse
Affiliation(s)
- Jun Torii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Satoshi Maesawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Daisuke Nakatsubo
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Focused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital
| | - Takahiko Tsugawa
- Focused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital
- Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospita
| | - Sachiko Kato
- Focused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital
- Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospita
| | | | - Sou Takai
- Department of Neurosurgery, Ichinomiya Municipal Hospital
| | - Masashi Shibata
- Focused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital
- Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospita
| | | | - Takashi Tsuboi
- Department of Neurology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masashi Suzuki
- Department of Neurology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| |
Collapse
|
25
|
Iijima K, Yokota H, Yamaguchi T, Nakano M, Ouchi T, Maki F, Takasaki M, Shimizu Y, Hori H, Iwamuro H, Sasanuma J, Watanabe K, Uno T. Predictors of thermal increase in magnetic resonance-guided focused ultrasound treatment for essential tremor: histogram analysis of skull density ratio values for 1024 elements. J Neurosurg 2022; 136:1381-1386. [PMID: 34653973 DOI: 10.3171/2021.5.jns21669] [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: 03/27/2021] [Accepted: 05/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sufficient thermal increase capable of generating thermocoagulation is indispensable for an effective clinical outcome in patients undergoing magnetic resonance-guided focused ultrasound (MRgFUS). The skull density ratio (SDR) is one of the most dominant predictors of thermal increase prior to treatment. However, users currently rely only on the average SDR value (SDRmean) as a screening criterion, although some patients with low SDRmean values can achieve sufficient thermal increase. The present study aimed to examine the numerical distribution of SDR values across 1024 elements to identify more precise predictors of thermal increase during MRgFUS. METHODS The authors retrospectively analyzed the correlations between the skull parameters and the maximum temperature achieved during unilateral ventral intermediate nucleus thalamotomy with MRgFUS in a cohort of 55 patients. In addition, the numerical distribution of SDR values was quantified across 1024 elements by using the skewness, kurtosis, entropy, and uniformity of the SDR histogram. Next, the authors evaluated the correlation between the aforementioned indices and a peak temperature > 55°C by using univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis was performed to compare the predictive ability of the indices. The diagnostic performance of significant factors was also assessed. RESULTS The SDR skewness (SDRskewness) was identified as a significant predictor of thermal increase in the univariate and multivariate logistic regression analyses (p < 0.001, p = 0.013). Moreover, the receiver operating characteristic curve analysis indicated that the SDRskewness exhibited a better predictive ability than the SDRmean, with area under the curve values of 0.847 and 0.784, respectively. CONCLUSIONS The SDRskewness is a more accurate predictor of thermal increase than the conventional SDRmean. The authors suggest setting the SDRskewness cutoff value to 0.68. SDRskewness may allow for the inclusion of treatable patients with essential tremor who would have been screened out based on the SDRmean exclusion criterion.
Collapse
Affiliation(s)
- Ken Iijima
- 1Department of Diagnostic Radiology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Hajime Yokota
- 2Department of Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba
| | - Toshio Yamaguchi
- 3Research Institute for Diagnostic Radiology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Masayuki Nakano
- 4Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Takahiro Ouchi
- 5Department of Neurology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Futaba Maki
- 5Department of Neurology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Masahito Takasaki
- 6Department of Anesthesiology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa; and
| | - Yasuhiro Shimizu
- 1Department of Diagnostic Radiology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Hiroki Hori
- 1Department of Diagnostic Radiology, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | | | - Jinichi Sasanuma
- 4Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Kazuo Watanabe
- 4Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa
| | - Takashi Uno
- 2Department of Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Stanziano M, Golfrè Andreasi N, Messina G, Rinaldo S, Palermo S, Verri M, Demichelis G, Medina JP, Ghielmetti F, Bonvegna S, Nigri A, Frazzetta G, D'Incerti L, Tringali G, DiMeco F, Eleopra R, Bruzzone MG. Resting State Functional Connectivity Signatures of MRgFUS Vim Thalamotomy in Parkinson's Disease: A Preliminary Study. Front Neurol 2022; 12:786734. [PMID: 35095731 PMCID: PMC8791196 DOI: 10.3389/fneur.2021.786734] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/02/2021] [Indexed: 12/03/2022] Open
Abstract
Magnetic Resonance-guided high-intensity Focused Ultrasound (MRgFUS) of the thalamic ventral intermediate nucleus (Vim) for tremor has increasingly gained interest as a new non-invasive alternative to standard neurosurgery. Resting state functional connectivity (rs-FC) correlates of MRgFUS have not been extensively investigated yet. A region of interest (ROI)-to-ROI rs-FC MRI “connectomic” analysis focusing on brain regions relevant for tremor was conducted on 15 tremor-dominant patients with Parkinson's disease who underwent MRgFUS. We tested whether rs-FC between tremor-related areas was modulated by MRgFUS at 1 and 3 months post-operatively, and whether such changes correlated with individual clinical outcomes assessed by the MDS-UPDRS-III sub items for tremor. Significant increase in FC was detected within bilateral primary motor (M1) cortices, as well as between bilateral M1 and crossed primary somatosensory cortices, and also between pallidum and the dentate nucleus of the untreated hemisphere. Correlation between disease duration and FC increase at 3 months was found between the putamen of both cerebral hemispheres and the Lobe VI of both cerebellar hemispheres, as well as between the Lobe VI of untreated cerebellar hemisphere with bilateral supplementary motor area (SMA). Drop-points value of MDS-UPDRS at 3 months correlated with post-treatment decrease in FC, between the anterior cingulate cortex and bilateral SMA, as well as between the Lobe VI of treated cerebellar hemisphere and the interpositus nucleus of untreated cerebellum. Tremor improvement at 3 months, expressed as percentage of intra-subject MDS-UPDRS changes, correlated with FC decrease between bilateral occipital fusiform gyrus and crossed Lobe VI and Vermis VI. Good responders (≥50% of baseline tremor improvement) showed reduced FC between bilateral SMA, between the interpositus nucleus of untreated cerebellum and the Lobe VI of treated cerebellum, as well as between the untreated SMA and the contralateral putamen. Good responders were characterized at baseline by crossed hypoconnectivity between bilateral putamen and M1, as well as between the putamen of the treated hemisphere and the contralateral SMA. We conclude that MRgFUS can effectively modulate brain FC within the tremor network. Such changes are associated with clinical outcome. The shifting mode of integration among the constituents of this network is, therefore, susceptible to external redirection despite the chronic nature of PD.
Collapse
Affiliation(s)
- Mario Stanziano
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy.,Neurosciences Department "Rita Levi Montalcini, " University of Turin, Turin, Italy
| | - Nico Golfrè Andreasi
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Messina
- Functional Neurosurgery Unit, Neurosurgery Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Rinaldo
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Palermo
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy.,European Innovation Partnership on Active and Healthy Ageing, Brussels, Belgium
| | - Mattia Verri
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Greta Demichelis
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jean Paul Medina
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Ghielmetti
- Health Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Salvatore Bonvegna
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Anna Nigri
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Ludovico D'Incerti
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Tringali
- Functional Neurosurgery Unit, Neurosurgery Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco DiMeco
- Neurosurgery Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy.,Pathophysiology and Transplantation Department, University of Milan, Milan, Italy.,Neurological Surgery Department, Johns Hopkins Medical School, Baltimore, MD, United States
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| |
Collapse
|
28
|
Binder DK, Shah BB, Elias WJ. Focused ultrasound and other lesioning in the treatment of tremor. J Neurol Sci 2022; 435:120193. [DOI: 10.1016/j.jns.2022.120193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/24/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
|
29
|
Wathen C, Yang AI, Hitti FL, Henry L, Chaibainou H, Baltuch GH. Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor in the Setting of Prior Craniotomy. Oper Neurosurg (Hagerstown) 2022; 22:61-65. [PMID: 35007218 DOI: 10.1227/ons.0000000000000012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy is a rapidly evolving therapy for the treatment of essential tremor. Although the skull is a major determinant of the delivery of acoustic energy to the target, how the presence of a prior craniotomy must be accounted for during lesioning is unclear. OBJECTIVE To demonstrate novel application of this therapeutic option in a patient with a history of prior craniotomies for unrelated intracranial pathologies. METHODS A 55-yr-old man with a history of right frontal craniotomy for resection of a colloid cyst underwent a left ventrointermedius nucleus thalamotomy through MRgFUS. The prior craniotomy flap was not excluded in the treatment plan; however, all bony defects and hardware were marked as "no-pass" regions. Clinical outcomes were collected at the 6-mo follow-up. RESULTS Transducer elements whose acoustic paths would have been altered by the craniotomy defect were turned off. Sonications reaching lesional temperatures of up to 56°C were successfully delivered. The procedure was well-tolerated, without any persistent intra-ablation or postablation adverse effects. The presence of a lesion was confirmed on MRI, which was associated with a significant reduction in the patient's tremor that was sustained at the 6-mo follow-up. CONCLUSION This case demonstrates the safety and efficacy of MRgFUS thalamotomy in a patient with prior craniotomies and highlights our strategy for acoustic lesioning in this setting.
Collapse
Affiliation(s)
- Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew I Yang
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frederick L Hitti
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Hanane Chaibainou
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon H Baltuch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
30
|
Ahmed AK, Guo S, Kelm N, Clanton R, Melhem ER, Gullapalli RP, Ksendzovsky A, Eisenberg HM, Miller TR, Gandhi D. Technical Comparison of Treatment Efficiency of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy and Pallidotomy in Skull Density Ratio-Matched Patient Cohorts. Front Neurol 2022; 12:808810. [PMID: 35126300 PMCID: PMC8813961 DOI: 10.3389/fneur.2021.808810] [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: 11/04/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Abstract
Objective MR-guided focused ultrasound (MRgFUS) is increasingly being used to treat patients with essential tremor (ET) and Parkinson's disease (PD) with thalamotomy and pallidotomy, respectively. Pallidotomy is performed off-center within the cranium compared to thalamotomy and may present challenges to therapeutic lesioning due to this location. However, the impact of target location on treatment efficiency and ability to create therapeutic lesions has not been studied. This study aimed to compare the physical efficiency of MRgFUS thalamotomy and pallidotomy. Methods Treatment characteristics were compared between patients treated with thalamotomy (n = 20) or pallidotomy (n = 20), matched by skull density ratios (SDR). Aspects of treatment efficiency were compared between these groups. Demographic and comparative statistics were conducted to assess these differences. Acoustic field simulations were performed to compare and validate the simulated temperature profile for VIM and GPi ablation. Results Lower SDR values were associated with greater energy requirement for thalamotomy (R2 = 0.197, p = 0.049) and pallidotomy (R2 = 0.342, p = 0.007). The impact of low SDR on efficiency reduction was greater for pallidotomy, approaching significance (p = 0.061). A nearly two-fold increase in energy was needed to reach 50°C in pallidotomy (10.9kJ) than in thalamotomy (5.7kJ), (p = 0.002). Despite lower energy requirement, the maximum average temperature reached was higher in thalamotomy (56.7°C) than in pallidotomy (55.0°C), (p = 0.017). Mean incident angle of acoustic beams was lesser in thalamotomy (12.7°) than in pallidotomy (18.6°), (p < 0.001). For all patients, a lesser mean incident angle correlated with a higher maximum average temperature reached (R2 = 0.124, p = 0.026), and less energy needed to reach 50°C (R2=0.134, p = 0.020). Greater skull thickness was associated with a higher maximum energy for a single sonication for thalamotomy (R2 = 0.206, p = 0.045) and pallidotomy (R2 = 0.403, p = 0.003). An acoustic and temperature field simulation validated similar findings for thalamotomy and pallidotomy in a single patient. Conclusion The centrally located VIM offers a more efficient location for therapeutic lesioning compared to GPi pallidotomy in SDR matched cohort of patients. The impact on therapeutic lesioning with lower SDR may be greater for pallidotomy patients. As newer off-center targets are investigated, these findings can inform patient selection and treatment requirements for lesion production.
Collapse
Affiliation(s)
- Abdul-Kareem Ahmed
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- *Correspondence: Abdul-Kareem Ahmed
| | - Sijia Guo
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | | | | | - Elias R. Melhem
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Rao P. Gullapalli
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Alexander Ksendzovsky
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Howard M. Eisenberg
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Timothy R. Miller
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Dheeraj Gandhi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| |
Collapse
|
31
|
Yuen J, Miller KJ, Klassen BT, Lehman VT, Lee KH, Kaufmann TJ. Hyperostosis in Combination With Low Skull Density Ratio: A Potential Contraindication for Magnetic Resonance Imaging-Guided Focused Ultrasound Thalamotomy. Mayo Clin Proc Innov Qual Outcomes 2022; 6:10-15. [PMID: 34977470 PMCID: PMC8704442 DOI: 10.1016/j.mayocpiqo.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Since its approval in treating a number of movement disorders, magnetic resonance imaging–guided focused ultrasound (MRgFUS) has been adopted rapidly as one of the standard treatment modalities internationally. However, the efficiency of the energy delivered by the ultrasonic waves is largely determined by the highly variable bone morphology and density characteristics of the skull. One of the widely accepted indices used to facilitate patient selection is the skull density ratio (SDR). Earlier literature suggested that an SDR of less than 0.4 would be unfavorable for MRgFUS treatment. Some prior studies have excluded patients with hyperostosis. However, there is little published data regarding the impact of other skull features such as hyperostosis on treatment success. We present the case of a 66-year-old man with medically refractory essential tremor who had an SDR of 0.38 and extensive hyperostosis frontalis interna and underwent attempted MRgFUS thalamotomy treatment. However, intraoperatively the treatment was unsuccessful in generating sufficiently elevated temperature to create a lesion of the usual desired volume, and as expected, there was minimal clinical improvement. For comparison, we also summarize a case series of 4 other patients with an SDR of less than 0.4 who had successful outcomes. We believe that SDR should not be used as the only means of selecting patients for MRgFUS. Instead, important factors such as hyperostosis should be taken into consideration for patient selection and pretreatment counseling.
Collapse
|
32
|
Arulpragasam AR, van 't Wout-Frank M, Barredo J, Faucher CR, Greenberg BD, Philip NS. Low Intensity Focused Ultrasound for Non-invasive and Reversible Deep Brain Neuromodulation-A Paradigm Shift in Psychiatric Research. Front Psychiatry 2022; 13:825802. [PMID: 35280168 PMCID: PMC8907584 DOI: 10.3389/fpsyt.2022.825802] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/18/2022] [Indexed: 01/15/2023] Open
Abstract
This article describes an emerging non-invasive neuromodulatory technology, called low intensity focused ultrasound (LIFU). This technology is potentially paradigm shifting as it can deliver non-invasive and reversible deep brain neuromodulation through acoustic sonication, at millimeter precision. Low intensity focused ultrasound's spatial precision, yet non-invasive nature sets it apart from current technologies, such as transcranial magnetic or electrical stimulation and deep brain stimulation. Additionally, its reversible effects allow for the causal study of deep brain regions implicated in psychiatric illness. Studies to date have demonstrated that LIFU can safely modulate human brain activity at cortical and subcortical levels. Due to its novelty, most researchers and clinicians are not aware of the potential applications and promise of this technique, underscoring the need for foundational papers to introduce the community to LIFU. This mini-review and synthesis of recent advances examines several key papers on LIFU administered to humans, describes the population under study, parameters used, and relevant findings that may guide future research. We conclude with a concise overview of some of the more pressing questions to date, considerations when interpreting new data from an emerging field, and highlight the opportunities and challenges in this exciting new area of study.
Collapse
Affiliation(s)
- Amanda R Arulpragasam
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, United States.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
| | - Mascha van 't Wout-Frank
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, United States.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States.,COBRE Center for Neuromodulation, Butler Hospital, Providence, RI, United States
| | - Jennifer Barredo
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, United States.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States.,COBRE Center for Neuromodulation, Butler Hospital, Providence, RI, United States
| | - Christiana R Faucher
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, United States
| | - Benjamin D Greenberg
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, United States.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States.,COBRE Center for Neuromodulation, Butler Hospital, Providence, RI, United States
| | - Noah S Philip
- VA RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, United States.,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States.,COBRE Center for Neuromodulation, Butler Hospital, Providence, RI, United States
| |
Collapse
|
33
|
Kim MJ, Park SH, Chang KW, Kim Y, Gao J, Kovalevsky M, Rachmilevitch I, Zadicario E, Chang WS, Jung HH, Chang JW. Technical and operative factors affecting magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: experience from 250 treatments. J Neurosurg 2021; 135:1780-1788. [PMID: 34020416 DOI: 10.3171/2020.11.jns202580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-guided focused ultrasound (MRgFUS) provides real-time monitoring of patients to assess tremor control and document any adverse effects. MRgFUS of the ventral intermediate nucleus (VIM) of the thalamus has become an effective treatment option for medically intractable essential tremor (ET). The aim of this study was to analyze the correlations of clinical and technical parameters with 12-month outcomes after unilateral MRgFUS thalamotomy for ET to help guide future clinical treatments. METHODS From October 2013 to January 2019, data on unilateral MRgFUS thalamotomy from the original pivotal study and continued-access studies from three different geographic regions were collected. Authors of the present study retrospectively reviewed those data and evaluated the efficacy of the procedure on the basis of improvement in the Clinical Rating Scale for Tremor (CRST) subscore at 1 year posttreatment. Safety was based on the rates of moderate and severe thalamotomy-related adverse events. Treatment outcomes in relation to various patient- and sonication-related parameters were analyzed in a large cohort of patients with ET. RESULTS In total, 250 patients were included in the present analysis. Improvement was sustained throughout the 12-month follow-up period, and 184 (73.6%) of 250 patients had minimal or no disability due to tremor (CRST subscore < 10) at the 12-month follow-up. Younger age and higher focal temperature (Tmax) correlated with tremor improvement in the multivariate analysis (OR 0.948, p = 0.013; OR 1.188, p = 0.025; respectively). However, no single statistically significant factor correlated with Tmax in the multivariate analysis. The cutoff value of Tmax in predicting a CRST subscore < 10 was 55.8°C. Skull density ratio (SDR) was positively correlated with heating efficiency (β = 0.005, p < 0.001), but no significant relationship with tremor improvement was observed. In the low-temperature group, 1-3 repetitions to the right target with 52°C ≤ Tmax ≤ 54°C was sufficient to generate sustained tremor suppression within the investigated follow-up period. The high-temperature group had a higher rate of balance disturbances than the low-temperature group (p = 0.04). CONCLUSIONS The authors analyzed the data of 250 patients with the aim of improving practices for patient screening and determining treatment endpoints. These results may improve the safety, efficacy, and efficiency of MRgFUS thalamotomy for ET.
Collapse
Affiliation(s)
- Myung Ji Kim
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - So Hee Park
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Kyung Won Chang
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Yuhee Kim
- 2InSightec Ltd., Tirat Carmel, Israel
| | - Jing Gao
- 2InSightec Ltd., Tirat Carmel, Israel
| | | | | | | | - Won Seok Chang
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Hyun Ho Jung
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Jin Woo Chang
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Maesawa S, Nakatsubo D, Tsugawa T, Kato S, Shibata M, Takai S, Torii J, Ishizaki T, Wakabayashi T, Saito R. Techniques, Indications, and Outcomes in Magnetic Resonance-guided Focused Ultrasound Thalamotomy for Tremor. Neurol Med Chir (Tokyo) 2021; 61:629-639. [PMID: 34470990 PMCID: PMC8592814 DOI: 10.2176/nmc.ra.2021-0187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Magnetic resonance (MR)-guided focused ultrasound surgery (MRgFUS) is the latest minimally invasive stereotactic procedure, and thalamotomy using this novel modality has demonstrated its effectiveness and safety, especially for patients with essential tremor (ET) and Parkinson's disease (PD). In Japan, the application of MRgFUS to treat ET and PD has recently been covered by health insurance. Technically, the transducer with 1024 elements emits ultrasound beams, which are then focused on the target with a phase control, resulting in optimal ablation by thermal coagulation. The technical advantages of MRgFUS are continuous intraoperative monitoring of clinical symptoms and MR images and fine adjustment of the target by the steering function. Postoperative tremor control is compatible with other modalities, although long-term follow-up is necessary. The adverse effects are usually transient and acceptable. Prognostic factors for good tremor control include high temperature and large lesion size. A high skull density ratio is a factor to achieve high temperature and large lesioning, but it may not be necessary and sufficient for clinical outcomes. For patients with advanced symptoms such as bilateral tremor or head/neck tremor, deep brain stimulation may be recommended because of the adjustability of stimulation and the possibility of bilateral treatment. Patients have high expectations of MRgFUS because of its non-invasiveness. To perform this treatment safely and effectively, physicians need to understand the technological aspects, the physiological principles. To choose the appropriate modality, physicians also should recognize the clinical advantages and disadvantages of MRgFUS compared to other modalities.
Collapse
Affiliation(s)
- Satoshi Maesawa
- Brain and Mind Research Center, Nagoya University
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Daisuke Nakatsubo
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Takahiko Tsugawa
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Sachiko Kato
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Masashi Shibata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Sou Takai
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Jun Torii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Tomotaka Ishizaki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Department of Neurosurgery, Kainan Hospital
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| |
Collapse
|
36
|
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.
Collapse
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
| | | |
Collapse
|
37
|
Yang AI, Hitti FL, Alabi OO, Joshi D, Chaibainou H, Henry L, Clanton R, Baltuch GH. Patient-specific effects on sonication heating efficiency during magnetic resonance-guided focused ultrasound thalamotomy. Med Phys 2021; 48:6588-6596. [PMID: 34532858 DOI: 10.1002/mp.15239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 01/09/2023] Open
Abstract
PURPOSE During magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for refractory tremor, high temperatures must be achieved and sustained for tissue necrosis. We assessed the impact of both patient-specific as well as procedure-related factors on the efficiency of acoustic energy transfer, or heating efficiency (HE). METHODS Retrospective analysis of 92 consecutive patients (857 sonications) with essential tremor or tremor-dominant Parkinson's disease treated at a single institution. Temperature elevations at the target were measured for each sonication with MR thermometry. HE of each sonication was defined as the ratio of peak temperature elevation and the delivered energy. HE was analyzed with respect to patient skull features (area, thickness, skull density ratio [SDR]), computed from CT scans, as well as demographic and clinical variables (age, sex, diagnosis, and duration of symptoms). RESULTS Across the full range of sonication energies that can be delivered with current devices (up to 36 kJ), average sonication HE was diminished in patients with lower SDR. In individual subjects, there was a progressive loss in HE as sonication energy was titrated up throughout the course of treatment, with a more rapid decline in patients with higher SDR. This energy-dependent loss in HE was not related to procedural factors, namely, the number of previous sonications, or the cumulative energy deposited during previous sonications. In contrast to SDR, neither skull area nor thickness was an independent predictor of average HE or the rate of its decline with increasing energies. In 11% of patients, all of whom with SDR < 0.45, sonication HE fell below the threshold to reach 54°C even with delivery of maximum energy. In contrast, temperatures ≥ 50°C could be obtained in all but one patient. CONCLUSIONS SDR is predictive of sonication HE, and determines patient-specific limits on the magnitude of temperature elevation that can be achieved with current devices. These data inform strategies for predictable lesioning in MRgFUS thalamotomy.
Collapse
Affiliation(s)
- Andrew I Yang
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frederick L Hitti
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Opeyemi O Alabi
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Disha Joshi
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hanane Chaibainou
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Gordon H Baltuch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
38
|
Bruno F, Catalucci A, Arrigoni F, Gagliardi A, Campanozzi E, Corridore A, Tommasino E, Pagliei V, Pertici L, Palumbo P, Sucapane P, Cerone D, Pistoia F, Di Cesare E, Barile A, Ricci A, Marini C, Splendiani A, Masciocchi C. Comprehensive Evaluation of Factors Affecting Tremor Relapse after MRgFUS Thalamotomy: A Case-Control Study. Brain Sci 2021; 11:brainsci11091183. [PMID: 34573204 PMCID: PMC8472207 DOI: 10.3390/brainsci11091183] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To identify possible relevant factors contributing to tremor relapse after MRgFUS thalamotomy in patients with essential tremor (ET) and Parkinson's disease (PD). METHODS We identified patients with tremor relapse from a series of 79 treatments in a single institution. The demographic and clinical characteristics of the study group patients were compared to those of patients who did not relapse in the same follow-up period. Imaging and procedural factors were compared using a control group matched for clinical and demographic characteristics. RESULTS Concerning clinical and demographic characteristics, we did not find statistically significant differences in gender and age. Seventy-three percent of patients with tremor relapse were Parkinson's disease patients. Using MRI, we found larger thalamotomy lesions at the 1-year follow-up in the control group with stable outcomes, compared to patients with tremor relapse. In the tractography evaluation, we found a more frequent eccentric position of the DRTt in patients with tremor relapse. CONCLUSIONS The most relevant determining factors for tremor relapse after MRgFUS thalamotomy appear to be tremor from Parkinson's disease and inaccurate thalamic targeting. Size of the thalamotomy lesion can also influence the outcome of treatment.
Collapse
Affiliation(s)
- Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy;
- Correspondence:
| | - Alessia Catalucci
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, 67100 L’Aquila, Italy; (A.C.); (E.D.C.)
| | - Francesco Arrigoni
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Alessio Gagliardi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Elena Campanozzi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Antonella Corridore
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Emanuele Tommasino
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Valeria Pagliei
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Leonardo Pertici
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Pierpaolo Palumbo
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy;
| | - Patrizia Sucapane
- Neurology, San Salvatore Hospital, 67100 L’Aquila, Italy; (P.S.); (D.C.)
| | - Davide Cerone
- Neurology, San Salvatore Hospital, 67100 L’Aquila, Italy; (P.S.); (D.C.)
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Ernesto Di Cesare
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, 67100 L’Aquila, Italy; (A.C.); (E.D.C.)
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | | | - Carmine Marini
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.A.); (A.G.); (E.C.); (A.C.); (E.T.); (V.P.); (L.P.); (F.P.); (A.B.); (C.M.); (A.S.); (C.M.)
| |
Collapse
|
39
|
Zhang H, Zhang Y, Xu M, Song X, Chen S, Jian X, Ming D. The Effects of the Structural and Acoustic Parameters of the Skull Model on Transcranial Focused Ultrasound. SENSORS 2021; 21:s21175962. [PMID: 34502853 PMCID: PMC8434628 DOI: 10.3390/s21175962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 01/02/2023]
Abstract
Transcranial focused ultrasound (tFUS) has great potential in brain imaging and therapy. However, the structural and acoustic differences of the skull will cause a large number of technical problems in the application of tFUS, such as low focus energy, focal shift, and defocusing. To have a comprehensive understanding of the skull effect on tFUS, this study investigated the effects of the structural parameters (thickness, radius of curvature, and distance from the transducer) and acoustic parameters (density, acoustic speed, and absorption coefficient) of the skull model on tFUS based on acrylic plates and two simulation methods (self-programming and COMSOL). For structural parameters, our research shows that as the three factors increase the unit distance, the attenuation caused from large to small is the thickness (0.357 dB/mm), the distance to transducer (0.048 dB/mm), and the radius of curvature (0.027 dB/mm). For acoustic parameters, the attenuation caused by density (0.024 dB/30 kg/m3) and acoustic speed (0.021 dB/30 m/s) are basically the same. Additionally, as the absorption coefficient increases, the focus acoustic pressure decays exponentially. The thickness of the structural parameters and the absorption coefficient of the acoustic parameters are the most important factors leading to the attenuation of tFUS. The experimental and simulation trends are highly consistent. This work contributes to the comprehensive and quantitative understanding of how the skull influences tFUS, which further enhances the application of tFUS in neuromodulation research and treatment.
Collapse
Affiliation(s)
- Hao Zhang
- Laboratory of Neural Engineering and Rehabilitation, Department of Biomedical Engineering, College of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China; (H.Z.); (M.X.); (S.C.)
| | - Yanqiu Zhang
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin 300070, China; (Y.Z.); (X.J.)
| | - Minpeng Xu
- Laboratory of Neural Engineering and Rehabilitation, Department of Biomedical Engineering, College of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China; (H.Z.); (M.X.); (S.C.)
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China;
| | - Xizi Song
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China;
| | - Shanguang Chen
- Laboratory of Neural Engineering and Rehabilitation, Department of Biomedical Engineering, College of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China; (H.Z.); (M.X.); (S.C.)
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China;
- National Key Laboratory of Human Factors Engineering, China Astronaut Research and Training Center, Beijing 100094, China
| | - Xiqi Jian
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin 300070, China; (Y.Z.); (X.J.)
| | - Dong Ming
- Laboratory of Neural Engineering and Rehabilitation, Department of Biomedical Engineering, College of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China; (H.Z.); (M.X.); (S.C.)
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China;
- Correspondence:
| |
Collapse
|
40
|
Zhang M, Rodrigues A, Zhou Q, Li G. Focused ultrasound: growth potential and future directions in neurosurgery. J Neurooncol 2021; 156:23-32. [PMID: 34410576 DOI: 10.1007/s11060-021-03820-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/31/2021] [Indexed: 12/18/2022]
Abstract
Over the past two decades, vast improvements in focused ultrasound (FUS) technology have made the therapy an exciting addition to the neurosurgical armamentarium. In this time period, FUS has gained US Food and Drug Administration (FDA) approval for the treatment of two neurological disorders, and ongoing efforts seek to expand the lesion profile that is amenable to ultrasonic intervention. In the following review, we highlight future applications for FUS therapy and compare its potential role against established technologies, including deep brain stimulation and stereotactic radiosurgery. Particular attention is paid to tissue ablation, blood-brain-barrier opening, and gene therapy. We also address technical and infrastructural challenges involved with FUS use and summarize the hurdles that must be overcome before FUS becomes widely accepted in the neurosurgical community.
Collapse
Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA. .,Center for Academic Medicine, Neurosurgery, Stanford University School of Medicine, MC 5327, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Adrian Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.,Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
41
|
Davidson B, Mithani K, Huang Y, Jones RM, Goubran M, Meng Y, Snell J, Hynynen K, Hamani C, Lipsman N. Technical and radiographic considerations for magnetic resonance imaging-guided focused ultrasound capsulotomy. J Neurosurg 2021; 135:291-299. [PMID: 32977311 DOI: 10.3171/2020.6.jns201302] [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] [Received: 04/17/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality that enables incisionless ablative neurosurgical procedures. Bilateral MRgFUS capsulotomy has recently been demonstrated to be safe and effective in treating obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). Preliminary evidence has suggested that bilateral MRgFUS capsulotomy can present increased difficulties in reaching lesional temperatures as compared to unilateral thalamotomy. The authors of this article aimed to study the parameters associated with successful MRgFUS capsulotomy lesioning and to present longitudinal radiographic findings following MRgFUS capsulotomy. METHODS Using data from 22 attempted MRgFUS capsulotomy treatments, the authors investigated the relationship between various sonication parameters and the maximal temperature achieved at the intracranial target. Lesion volume and morphology were analyzed longitudinally using structural and diffusion tensor imaging. A retreatment procedure was attempted in one patient, and their postoperative imaging is presented. RESULTS Skull density ratio (SDR), skull thickness, and angle of incidence were significantly correlated with the maximal temperature achieved. MRgFUS capsulotomy lesions appeared similar to those following MRgFUS thalamotomy, with three concentric zones observed on MRI. Lesion volumes regressed substantially over time following MRgFUS. Fractional anisotropy analysis revealed a disruption in white matter integrity, followed by a gradual return to near-baseline levels concurrent with lesion regression. In the patient who underwent retreatment, successful bilateral lesioning was achieved, and there were no adverse clinical or radiographic events. CONCLUSIONS With the current iteration of MRgFUS technology, skull-related parameters such as SDR, skull thickness, and angle of incidence should be considered when selecting patients suitable for MRgFUS capsulotomy. Lesions appear to follow morphological patterns similar to what is seen following MRgFUS thalamotomy. Retreatment appears to be safe, although additional cases will be necessary to further evaluate the associated safety profile.
Collapse
Affiliation(s)
- Benjamin Davidson
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - Karim Mithani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - Yuexi Huang
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ryan M Jones
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Maged Goubran
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
- 7Department of Medical Biophysics, University of Toronto; and
| | - Ying Meng
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - John Snell
- 5The Focused Ultrasound Foundation, Charlottesville
- 6Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Kullervo Hynynen
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
- 7Department of Medical Biophysics, University of Toronto; and
- 8Institute of Biomaterials and Biomedical Engineering, Toronto, Ontario, Canada
| | - Clement Hamani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - Nir Lipsman
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
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: 18] [Impact Index Per Article: 6.0] [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.
Collapse
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
| |
Collapse
|
44
|
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: 16] [Impact Index Per Article: 5.3] [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.
Collapse
|
45
|
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: 26] [Impact Index Per Article: 8.7] [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.
Collapse
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
| |
Collapse
|
46
|
Fukutome K, Kuga Y, Ohnishi H, Hirabayashi H, Nakase H. What factors impact the clinical outcome of magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor? J Neurosurg 2021; 134:1618-1623. [PMID: 32357330 DOI: 10.3171/2020.2.jns192814] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/25/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is a novel and useful treatment for essential tremor (ET); however, the factors impacting treatment outcome are unknown. The authors conducted this study to determine the factors affecting the outcome of MRgFUS. METHODS From May 2016 through August 2017, 15 patients with ET were admitted to Ohnishi Neurological Center and treated with MRgFUS. To determine the factors impacting treatment outcome, the authors retrospectively studied correlations between the Clinical Rating Scale for Tremor (CRST) improvement rate and age, disease duration, baseline CRST score, skull density ratio (SDR), skull volume, maximum delivered energy, or maximum temperature. RESULTS The mean CRST score was 18.5 ± 5.8 at baseline and 4.6 ± 5.7 at 1 year. The rate of improvement in the CRST score was 80% ± 22%. Younger age and lower baseline CRST score were correlated with a higher CRST improvement rate (p = 0.025 and 0.007, respectively). To obtain a CRST improvement rate ≥ 50%, a maximum temperature ≥ 55°C was necessary. There was no correlation between SDR and CRST improvement rate (p = 0.658). A lower SDR and higher skull volume required significantly higher maximum delivered energy (p = 0.014 and 0.016, respectively). A higher maximum temperature was associated with a significantly larger lesion volume (p = 0.026). CONCLUSIONS Younger age and lower baseline CRST score were favorable outcome factors. It is important to assess predictive factors when applying MRgFUS.
Collapse
Affiliation(s)
- Kenji Fukutome
- 1Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo
| | - Yoshihiro Kuga
- 1Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo
| | - Hideyuki Ohnishi
- 1Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo
| | - Hidehiro Hirabayashi
- 1Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo
- 2Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara
| | - Hiroyuki Nakase
- 3Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
47
|
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.
Collapse
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
| |
Collapse
|
48
|
Chang KW, Rachmilevitch I, Chang WS, Jung HH, Zadicario E, Prus O, Chang JW. Safety and Efficacy of Magnetic Resonance-Guided Focused Ultrasound Surgery With Autofocusing Echo Imaging. Front Neurosci 2021; 14:592763. [PMID: 33510610 PMCID: PMC7835836 DOI: 10.3389/fnins.2020.592763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/30/2020] [Indexed: 02/01/2023] Open
Abstract
Objective Magnetic resonance-guided focused ultrasound surgery (MRgFUS) lesioning is a new treatment for brain disorders. However, the skull is a major barrier of ultrasound sonication in MRgFUS because it has an irregular surface and varies its size and shape among individuals. We recently developed the concept of skull density ratio (SDR) to select candidates for MRgFUS from among patients with essential tremor (ET). However, SDR is not the only factor contributing to successful MRgFUS lesioning treatment-refining the target through exact measurement of the ultrasonic echo in the transducer also improves treatment efficacy. In the present study, we carried out MRgFUS lesioning using an autofocusing echo imaging technique. We aimed to evaluate the safety and efficacy of this new approach, especially in patients with low SDR in whom previous focusing methods have failed. Methods From December 2019 to March 2020, we recruited 10 patients with ET or Parkinson's disease (PD) who had a low SDR. Two patients dropped out of the trial due to the screening failure of other medical diseases. In total, eight patients were included: six with ET who underwent MRgFUS thalamotomy and two with PD who underwent MRgFUS pallidotomy. The autofocusing echo imaging technique was used in all cases. Results The mean SDR of the patients with ET was 0.34 (range: 0.29-0.39), while that of the patients with PD was 0.41 (range: 0.38-0.44). The mean skull volume of patients with ET was 280.57 cm3 (range: 227-319 cm3), while that of the patients with PD was 287.13 cm3 (range: 271-303 cm3). During MRgFUS, a mean of 15 sonications were performed, among which a mean of 5.63 used the autofocusing technique. The mean maximal temperature (Tmax) achieved was 55.88°C (range: 52-59°C), while the mean energy delivered was 34.75 kJ (range: 20-42 kJ) among all patients. No serious adverse events occurred during or after treatment. Tmax or sonication factors (skull volume, SDR, sonication number, autofocusing score, similarity score, energy range, and power) were not correlated with autofocusing technique (p > 0.05, autofocusing score showed a p-value of 0.071). Conclusion Using autofocusing echo imaging lesioning, a safe and efficient MRgFUS treatment, is available even for patients with a low SDR. Therefore, the indications for MRgFUS lesioning could be expanded to include patients with ET who have an SDR < 0.4 and those with PD who have an SDR < 0.45. Clinical Trial Registration clinicaltrials.gov, identifier: NCT03935581.
Collapse
Affiliation(s)
- Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | | | | | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
49
|
Schafer ME, Spivak NM, Korb AS, Bystritsky A. Design, Development, and Operation of a Low-Intensity Focused Ultrasound Pulsation (LIFUP) System for Clinical Use. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2021; 68:54-64. [PMID: 32746201 DOI: 10.1109/tuffc.2020.3006781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Noninvasive low-intensity focused ultrasound pulsation (LIFUP) neuromodulation provides a unique approach to both investigating and treating the brain. This work describes a well-calibrated, simple-to-use ultrasound stimulation system for neuromodulation studies. It provides a single-element 650-kHz transducer design and a straightforward control mechanism, with extensive calibration and internal electronic monitoring to prevent unwanted over or under treatment. One goal of this approach is to relieve researchers of many of the details associated with developing their own exposure equipment. A unique transducer positioning system and distinctive MRI fiducial targets simplify alignment and targeting. The system design, control software, calibration, and alignment techniques are described in detail. Examples of transducer targeting and neurostimulation using the system are provided.
Collapse
|
50
|
Badran BW, Caulfield KA, Stomberg-Firestein S, Summers PM, Dowdle LT, Savoca M, Li X, Austelle CW, Short EB, Borckardt JJ, Spivak N, Bystritsky A, George MS. Sonication of the anterior thalamus with MRI-Guided transcranial focused ultrasound (tFUS) alters pain thresholds in healthy adults: A double-blind, sham-controlled study. Brain Stimul 2020; 13:1805-1812. [PMID: 33127579 PMCID: PMC7888561 DOI: 10.1016/j.brs.2020.10.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Transcranial focused ultrasound (tFUS) is a noninvasive brain stimulation method that may modulate deep brain structures. This study investigates whether sonication of the right anterior thalamus would modulate thermal pain thresholds in healthy individuals. Methods: We enrolled 19 healthy individuals in this three-visit, double-blind, sham-controlled, crossover trial. Participants first underwent a structural MRI scan used solely for tFUS targeting. They then attended two identical experimental tFUS visits (counterbalanced by condition) at least one week apart. Within the MRI scanner, participants received two, 10-min sessions of either active or sham tFUS spread 10 min apart targeting the right anterior thalamus [fundamental frequency: 650 kHz, Pulse repetition frequency: 10 Hz, Pulse Width: 5 ms, Duty Cycle: 5%, Sonication Duration: 30s, Inter-Sonication Interval: 30 s, Number of Sonications: 10, ISPTA.0 995 mW/cm2, ISPTA.3 719 mW/cm2, Peak rarefactional pressure 0.72 MPa]. The primary outcome measure was quantitative sensory thresholding (QST), measuring sensory, pain, and tolerance thresholds to a thermal stimulus applied to the left forearm before and after right anterior thalamic tFUS. Results: The right anterior thalamus was accurately sonicated in 17 of the 19 subjects. Thermal pain sensitivity was significantly attenuated after active tFUS. The pre-post x active-sham interaction was significant (F(1,245.95) = 4.03, p = .046). This interaction indicates that in the sham stimulation condition, thermal pain thresholds decreased 1.08 °C (SE = 0.28) pre-post session, but only decreased .51 °C (SE = 0.30) pre-post session in the active stimulation group. Conclusions: Two 10-min sessions of anterior thalamic tFUS induces antinociceptive effects in healthy individuals. Future studies should optimize the parameter space, dose and duration of this effect which may lead to multi-session tFUS interventions for pain disorders.
Collapse
Affiliation(s)
- Bashar W Badran
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Kevin A Caulfield
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Sasha Stomberg-Firestein
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Philipp M Summers
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan T Dowdle
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA
| | - Matt Savoca
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Xingbao Li
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Christopher W Austelle
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - E Baron Short
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey J Borckardt
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Norman Spivak
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Mark S George
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| |
Collapse
|