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Pereira GM, Soares NM, Rieder CRDM, Alva TAP. Stereotatic radiosurgery for the treatment of motor symptoms in Parkinson's disease: A systematic review. J Med Imaging Radiat Sci 2024; 55:146-157. [PMID: 38342737 DOI: 10.1016/j.jmir.2024.01.001] [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: 12/06/2023] [Accepted: 01/08/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Stereotaxic Radiosurgery (SRS) is a non-invasive lesioning technique for movement disorders when patients cannot undergo DBS due to medical comorbidities. OBJECTIVE To describe and summarize the literature on SRS's application and physical parameters for Parkinson's disease (PD) motor symptoms. METHODS The MEDLINE/PUBMED and EMBASE databases were searched in July 2022 following the PRISMA guideline. Two independent reviewers screened data from 425 articles. The level of evidence followed the Oxford Centre for Evidence-Based Medicine. Pertinent details for each study regarding participants, physical parameters, and results were extracted. RESULTS Twelve studies reported that 454 PD patients underwent Gamma KnifeⓇ (GK). The mean improvement time of the treated symptoms was three months after GK. Tremor is the most common symptom investigated, with success rates ranging from 47.5% to 93.9%. Few studies were conducted for caudatotomy (GKC) and pallidotomy (GKP), which presented an improvement for dyskinesia and bradykinesia. Physical parameters were similar with doses ranging from 110 to 200 Gy, use of a 4-mm collimator with an advanced imaging locator system, and coordinates were obtained from available stereotactic atlases. CONCLUSIONS GK thalamotomy is a good alternative for treating tremor; however, its effects are delayed, and there are cases in which it can regress after years. The outcomes of GKC and GKP seem to be promising. The existing studies are more limited, and effects need to be better investigated.
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Affiliation(s)
- Gabriela Magalhães Pereira
- Exact and Applied Social Sciences Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil; Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil; Clinical research center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil.
| | - Nayron Medeiros Soares
- Exact and Applied Social Sciences Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil; Clinical research center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Carlos Roberto de Mello Rieder
- Department of Clinical Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Thatiane Alves Pianoschi Alva
- Exact and Applied Social Sciences Department, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul, Brazil
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Nabiullina DI, Galimova RM, Illarioshkin SN, Buzaev IV, Safin SM, Akhmadeeva GN, Mukhamadeeva NR, Krekotin DK. [Experience of staged and simultaneous bilateral thalamotomy using MR-guided focused ultrasound in the treatment of essential tremor]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:65-73. [PMID: 37490667 DOI: 10.17116/jnevro202312307165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To show that effective and safe bilateral MR-guided focused ultrasound (MRgFUS) treatment of essential tremor (ET) is achievable. MATERIAL AND METHODS Four male patients underwent bilateral thalamotomy. Two patients underwent staged thalamotomy, with the ≥12 month interval between operations. Two patients underwent simultaneous bilateral thalamotomy. RESULTS After six months, all patients noted a significant reduction in symptoms on both sides: when assessing tremors with the Clinical Rating Scale for Tremor, the severity of hyperkinesis decreased by 57.5-69.7%. We did not observe any complications in any of the cases. CONCLUSION Our experience indicates that simultaneous bilateral MRI-guided focused ultrasound treatment of ET can be performed safely and effectively. Further research is necessary to estimate the effectiveness and adverse effect rates.
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Affiliation(s)
- D I Nabiullina
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
| | - R M Galimova
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
- Bashkir State Medical University, Ufa, Russia
| | | | - I V Buzaev
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
- Bashkir State Medical University, Ufa, Russia
| | - Sh M Safin
- Bashkir State Medical University, Ufa, Russia
| | - G N Akhmadeeva
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
| | - N R Mukhamadeeva
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
| | - D K Krekotin
- Buzaev Clinics of Intellectual Neurosurgery the International Medical Center, Ufa, Russia
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Gunawan K, Santoso F, Aman RA, Tandian D, Nugroho SW. Gamma Knife Radiosurgery for Tremor Movement Disorder: A Systematic Review. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIM: The goal of this systematic review is to know how outcome of GKRS for tremor movement disorder.
METHODS: Literature searching was conducted in database online that is PubMed, Science Direct, Cochrane Library, Google Scholar and hand searching with keyword “gamma knife,” “parkinson,” “tremor,” “success rate,” “good outcome,” and “free tremor.” Articles included were full-text and observational study and written in Bahasa or English.
RESULTS: This systematic review used only six articles, which five of them examined ET and the other PD. Majority of studies used Fahn-Tolosa-Marin clinical tremor rating scale (TRS) for evaluation pre- and post-GKRS. However, the duration of follow-up is varies from <1 year until 76 months. The doses are also varies from 110 until 150 Gy (Median 120–130 Gy). A study report that 1 year after GKRS, ET patients could have 58% improvement in writing and 51% in drawing. Other study, which of median follow-up was 36 months, had 69% of samples showed improvement in both action tremor and writing scores. Ohye et al. in 2008 reported that since 1992, they have 80% successful in GK thalamotomy for tremor, either ET or PD. Similar author has been done multivariate study in six Japanese institution which of result was GKRS thalamotomy could be alternative treatment for intractable tremor, either ET or PD until 24 months. All of the study about ET have improvement results with GKRS in ventralis intermedius (VIM) of the thalamus. However, one study about PD evaluated GKRS in subthalamic nucleus (STN) of thalamus and got neurological complication with higher-risk of GKRS hyper response.
CONCLUSION: GKRS, especially VIM thalamotomy, offers effective and safe alternative for ET and PD. We need more studies with approved method to answer this clinical question accurately. However, the study comparing GKRS and open surgical is still needed.
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Deuschl G, Antonini A, Costa J, Śmiłowska K, Berg D, Corvol J, Fabbrini G, Ferreira J, Foltynie T, Mir P, Schrag A, Seppi K, Taba P, Ruzicka E, Selikhova M, Henschke N, Villanueva G, Moro E. European Academy of Neurology/Movement Disorder Society ‐ European Section guideline on the treatment of Parkinson's disease: I. Invasive therapies. Eur J Neurol 2022; 29:2580-2595. [DOI: 10.1111/ene.15386] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Günther Deuschl
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience University of Padua Padua Italy
| | - Joao Costa
- Faculdade de Medicina da Universidade de Lisboa Lisbon Portugal
| | - Katarzyna Śmiłowska
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Daniela Berg
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Jean‐Christophe Corvol
- Institut du Cerveau–Paris Brain Institute Assistance Publique Hôpitaux de Paris Pitié‐Salpêtrière Hospital Department of Neurology, Centre d'Investigation Clinique Neurosciences Sorbonne Université Paris France
| | - Giovanni Fabbrini
- Department Human Neurosciences Sapienza University of Rome Rome Italy
- Neuromed Rome Italy
| | - Joaquim Ferreira
- Faculdade de Medicina Universidade de Lisboa Lisbon Portugal
- Instituto de Medicina Molecular João Lobo Antunes Lisbon Portugal
- Campus Neurológico Torres Vedras Portugal
| | - Tom Foltynie
- Department of Clinical & Movement Neurosciences Institute of Neurology London UK
| | - Pablo Mir
- Unidad de Trastornos del Movimiento Servicio de Neurología y Neurofisiología Clínica Instituto de Biomedicina de Sevilla Hospital Universitario Virgen del Rocío/Universidad de Sevilla Seville Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas Madrid Spain
- Departamento de Medicina Facultad de Medicina Universidad de Sevilla Seville Spain
| | - Annette Schrag
- Institute of Neurology, University Clinic London London UK
| | - Klaus Seppi
- Klinik f. Neurologie Medizinische Universität Innsbruck Innsbruck Austria
| | - Pille Taba
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine University of Tartu Tartu Estonia
- Tartu University Hospital Tartu Estonia
| | - Evzen Ruzicka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czechia
| | - Marianna Selikhova
- Department of Neurology Pirogov Russian National Research Medical University Moscow Russia
| | | | | | - Elena Moro
- Division of Neurology, Grenoble, Grenoble Institute of Neurosciences Grenoble Alpes University Grenoble France
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Deuschl G, Antonini A, Costa J, Śmiłowska K, Berg D, Corvol J, Fabbrini G, Ferreira J, Foltynie T, Mir P, Schrag A, Seppi K, Taba P, Ruzicka E, Selikhova M, Henschke N, Villanueva G, Moro E. European Academy of Neurology/Movement Disorder Society‐European Section Guideline on the Treatment of Parkinson's Disease: I. Invasive Therapies. Mov Disord 2022; 37:1360-1374. [DOI: 10.1002/mds.29066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Affiliation(s)
- Günther Deuschl
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience University of Padua Padua Italy
| | - Joao Costa
- Faculdade de Medicina da Universidade de Lisboa Lisbon Portugal
| | - Katarzyna Śmiłowska
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Daniela Berg
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Jean‐Christophe Corvol
- Institut du Cerveau‐Paris Brain Institute, Assistance Publique Hôpitaux de Paris, Pitié‐Salpêtrière Hospital, Department of Neurology, Centre d'Investigation Clinique Neurosciences Sorbonne Université Paris France
| | - Giovanni Fabbrini
- Department Human Neurosciences Sapienza University of Rome Rome Italy
- IRCCS Neuromed Rome Italy
| | - Joaquim Ferreira
- Faculdade de Medicina Universidade de Lisboa Lisbon Portugal
- Instituto de Medicina Molecular João Lobo Antunes Lisbon Portugal
- Campus Neurológico Torres Vedras Portugal
| | - Tom Foltynie
- Department of Clinical & Movement Neurosciences Institute of Neurology London UK
| | - Pablo Mir
- Unidad de Trastornos del Movimiento Servicio de Neurología y Neurofisiología Clínica Instituto de Biomedicina de Sevilla Hospital Universitario Virgen del Rocío/Universidad de Sevilla Seville Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas Madrid Spain
- Departamento de Medicina Facultad de Medicina Universidad de Sevilla Seville Spain
| | - Annette Schrag
- Institute of Neurology, University Clinic London London UK
| | - Klaus Seppi
- Klinik f. Neurologie Medizinische Universität Innsbruck Innsbruck Austria
| | - Pille Taba
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine University of Tartu Tartu Estonia
- Tartu University Hospital Tartu Estonia
| | - Evzen Ruzicka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czechia
| | | | | | | | - Elena Moro
- Division of Neurology, Grenoble, Grenoble Institute of Neurosciences Grenoble Alpes University Grenoble France
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Fukutome K, Hirabayashi H, Osakada Y, Kuga Y, Ohnishi H. Bilateral Magnetic Resonance Imaging-Guided Focused Ultrasound Thalamotomy for Essential Tremor. Stereotact Funct Neurosurg 2021; 100:44-52. [PMID: 34515233 DOI: 10.1159/000518662] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Essential tremor is the most common movement disorder in adults. Bilateral symptoms are typical; however, bilateral thalamotomy for essential tremor is associated with a high probability of adverse events. We retrospectively investigated the efficacy and safety of staged bilateral ventral intermediate nucleus thalamotomy for refractory essential tremor using magnetic resonance imaging-guided focused ultrasound. METHODS We enrolled 5 consecutive patients with refractory essential tremor between September 2016 and March 2020. Patients underwent a second operation at least 1 year after the first operation. The second lesion was created asymmetrically to the first lesion. RESULTS Mean patient age was 57.6 years, and the mean interval between the 2 operations was 27.8 months. The second lesion center was superior to the first lesion in all patients. The mean baseline, second preoperative, and second postoperative Clinical Rating Scale for Tremor total scores were 63.6, 49.2, and 21.8, respectively. The mean baseline, second preoperative, and second postoperative Clinical Rating Scale for Tremor part C scores were 18.4, 8.2, and 2.6, respectively. One patient had permanent adverse events of slight dysarthria and discomfort in the tongue. No patient experienced dysphagia or cognitive dysfunction after the second operation. Four of the 5 patients were satisfied with the results of the bilateral treatment, including the patient who had permanent adverse events. CONCLUSIONS Magnetic resonance imaging-guided focused ultrasound is an effective method for bilateral thalamotomy when adhering to the following considerations: (1) asymmetrical lesions are created and (2) sufficient interval (>1 year) between operations.
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Affiliation(s)
- Kenji Fukutome
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan.,Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Hidehiro Hirabayashi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan.,Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Yosuke Osakada
- Department of Neurology, Ohnishi Neurological Center, Akashi, Japan
| | - Yoshihiro Kuga
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan
| | - Hideyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Japan
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Sharma VD, Patel M, Miocinovic S. Surgical Treatment of Parkinson's Disease: Devices and Lesion Approaches. Neurotherapeutics 2020; 17:1525-1538. [PMID: 33118132 PMCID: PMC7851282 DOI: 10.1007/s13311-020-00939-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 10/23/2022] Open
Abstract
Surgical treatments have transformed the management of Parkinson's disease (PD). Therapeutic options available for the management of PD motor complications include deep brain stimulation (DBS), ablative or lesioning procedures (pallidotomy, thalamotomy, subthalamotomy), and dopaminergic medication infusion devices. The decision to pursue these advanced treatment options is typically done by a multidisciplinary team by considering factors such as the patient's clinical characteristics, efficacy, ease of use, and risks of therapy with a goal to improve PD symptoms and quality of life. DBS has become the most widely used surgical therapy, although there is a re-emergence of interest in ablative procedures with the introduction of MR-guided focused ultrasound. In this article, we review DBS and lesioning procedures for PD, including indications, selection process, and management strategies.
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Affiliation(s)
- Vibhash D Sharma
- Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Blvd, MS 3042, Kansas City, KS, 66160, USA.
| | - Margi Patel
- Department of Neurology, Emory University, Atlanta, GA, USA
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The Role of Stereotactic Ablative Radiotherapy in Oncological and Non-Oncological Clinical Settings: Highlights from the 7th Meeting of AIRO – Young Members Working Group (AIRO Giovani). TUMORI JOURNAL 2018. [DOI: 10.1177/1778.19280] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Martínez-Moreno NE, Sahgal A, De Salles A, Hayashi M, Levivier M, Ma L, Paddick I, Régis J, Ryu S, Slotman BJ, Martínez-Álvarez R. Stereotactic radiosurgery for tremor: systematic review. J Neurosurg 2018; 130:589-600. [PMID: 29473775 DOI: 10.3171/2017.8.jns17749] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 08/15/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this systematic review is to offer an objective summary of the published literature relating to stereotactic radiosurgery (SRS) for tremor and consensus guideline recommendations. METHODS This systematic review was performed up to December 2016. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The following key words were used: "radiosurgery" and "tremor" or "Parkinson's disease" or "multiple sclerosis" or "essential tremor" or "thalamotomy" or "pallidotomy." The search strategy was not limited by study design but only included key words in the English language, so at least the abstract had to be in English. RESULTS A total of 34 full-text articles were included in the analysis. Three studies were prospective studies, 1 was a retrospective comparative study, and the remaining 30 were retrospective studies. The one retrospective comparative study evaluating deep brain stimulation (DBS), radiofrequency thermocoagulation (RFT), and SRS reported similar tremor control rates, more permanent complications after DBS and RFT, more recurrence after RFT, and a longer latency period to clinical response with SRS. Similar tremor reduction rates in most of the reports were observed with SRS thalamotomy (mean 88%). Clinical complications were rare and usually not permanent (range 0%-100%, mean 17%, median 2%). Follow-up in general was too short to confirm long-term results. CONCLUSIONS SRS to the unilateral thalamic ventral intermediate nucleus, with a dose of 130-150 Gy, is a well-tolerated and effective treatment for reducing medically refractory tremor, and one that is recommended by the International Stereotactic Radiosurgery Society.
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Affiliation(s)
- Nuria E Martínez-Moreno
- 1Department of Radiosurgery and Functional Neurosurgery, Ruber International Hospital, Madrid, Spain
| | - Arjun Sahgal
- 2Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Antonio De Salles
- 3Department of Neurosurgery, University of California, Los Angeles, California
| | - Motohiro Hayashi
- 4Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Marc Levivier
- 5Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- 6Division of Physics, Department of Radiation Oncology, University of California, San Francisco, California
| | - Ian Paddick
- 7Division of Physics, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Régis
- 8Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Sam Ryu
- 9Department of Radiation Oncology, Stony Brook University, Stony Brook, New York; and
| | - Ben J Slotman
- 10Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Roberto Martínez-Álvarez
- 1Department of Radiosurgery and Functional Neurosurgery, Ruber International Hospital, Madrid, Spain
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Niranjan A, Raju SS, Monaco EA, Flickinger JC, Lunsford LD. Is staged bilateral thalamic radiosurgery an option for otherwise surgically ineligible patients with medically refractory bilateral tremor? J Neurosurg 2018; 128:617-626. [DOI: 10.3171/2016.11.jns162044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEUnilateral Gamma Knife thalamotomy (GKT) is a well-established treatment for patients with medically refractory tremor who are not eligible for invasive procedures due to increased risk of compications. The purpose of this study was to evaluate whether staged bilateral GKT provides benefit with acceptable risk to patients suffering from disabling medically refractory bilateral tremor.METHODSEleven patients underwent staged bilateral GKT during a 17-year period (1999–2016). Eight patients had essential tremor (ET), 2 had Parkinson's disease (PD)–related tremor, and 1 had multiple-sclerosis (MS)–related tremor. For the first GKT, a median maximum dose of 140 Gy was delivered to the posterior-inferior region of the nucleus ventralis intermedius (VIM) through a single isocenter with 4-mm collimators. Patients who benefitted from unilateral GKT were eligible for a contralateral GKT 1–2 years later (median 22 months). For the second GKT, a median maximum dose of 130 Gy was delivered to the opposite VIM nucleus to a single 4-mm isocenter. The Fahn-Tolosa-Marin (FTM) clinical tremor rating scale was used to score tremor, drawing, and drinking before and after each GKT. The FTM writing score was assessed only for the dominant hand before and after the first GKT. The Karnofsky Performance Status (KPS) was used to assess quality of life and activities of daily living before and after the first and second GKT.RESULTSThe median time to last follow-up after the first GKT was 35 months (range 11–70 months). All patients had improvement in at least 1 FTM score after the first GKT. Three patients (27.3%) had tremor arrest and complete restoration of function (noted via FTM tremor, writing, drawing, and drinking scores equaling zero). No patient had tremor recurrence or diminished tremor relief after the first GKT. One patient experienced new temporary neurological deficit (contralateral lower-extremity hemiparesis) from the first GKT. The median time to last follow-up after the second GKT was 12 months (range 2–70 months). Nine patients had improvement in at least 1 FTM score after the second GKT. Two patients had tremor arrest and complete restoration of function. No patient experienced tremor recurrence or diminished tremor relief after the second GKT. No patient experienced new neurological or radiological adverse effect from the second GKT. Statistically significant improvements were noted in the KPS score following the first and second GKT.CONCLUSIONSStaged bilateral GKT provided effective relief for medically refractory, disabling, bilateral tremor without increased risk of neurological complications. It is an appropriate strategy for carefully selected patients with medically refractory bilateral tremor who are not eligible for deep brain stimulation.
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Affiliation(s)
| | - Sudesh S. Raju
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Lozano CS, Tam J, Lozano AM. The changing landscape of surgery for Parkinson's Disease. Mov Disord 2017; 33:36-47. [PMID: 29194808 DOI: 10.1002/mds.27228] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 11/07/2022] Open
Abstract
Neurosurgical interventions have been used to treat PD for over a century. We examined the changing landscape of surgery for PD to appraise the value of various procedures in the context of advances in our understanding and technology. We assessed the number of articles published on neurosurgical procedures for PD over time as an albeit imprecise surrogate for their usage level. We identified over 8,000 publications associated with PD surgery. Over half the publications were on DBS. The field of DBS for PD showed a rapid rise in articles, but is now in a steady state. Thalamotomy and, to a lesser extent, pallidotomy follow a biphasic publication distribution with peaks approximately 30 years apart. Articles on gene therapy and transplantation experienced initial rapid rises and significant recent declines. Procedures using novel technologies, including gamma knife and focused ultrasound, are emerging, but are yet to have significant impact as measured by publication numbers. Pallidotomy and thalamotomy are prominent examples of procedures that were popular, declined, and re-emerged and redeclined. Transplantation and gene therapy have never broken into clinical practice. DBS overtook all procedures as the dominant surgical intervention and drove widespread use of surgery for PD. Notwithstanding, the number of DBS articles appears to have plateaued. As advances continue, emerging treatments may compete with DBS in the future. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Christopher S Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Tam
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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12
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Revisiting bilateral thalamotomy for tremor. Clin Neurol Neurosurg 2017; 158:103-107. [PMID: 28505539 DOI: 10.1016/j.clineuro.2017.04.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 03/28/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Abstract
MRI guided focused ultrasound surgery (MRgFUS) has been FDA approved for unilateral treatment of essential tremor (ET). Before this non-incisional lesioning method can be applied to the treatment of both hemispheres the previous experience with bilateral thalamic ablation must be addressed. In particular, the high incidence of worsening of speech and balance associated with bilateral surgical thalamotomy, a rationale for the development of deep brain stimulation. The highest incidence of these complication occurred in the early years of surgery for movement disorders, when neither MRI nor current stereotactic methods were available. The vast majority of these initial patients suffering these complications had Parkinson's disease where approximately 30% developed worsening dysarthria and ataxia after bilateral thalamotomy. Patients suffering these complications commonly had baseline abnormalities in speech and balance or worsening symptoms after a first unilateral procedure. The more contemporary experience with bilateral thalamotomy in the ET population is both much more limited in patient numbers (includes patients after Gamma Knife radiosurgery), and shows a much lower rate of these complications (approximately 5%). This more recent experience suggests that bilateral thalamotomy using closed incisionless methods such as MRgFUS has the potential to safely improve ET patients with axial or bilateral limb involvement, if done in a staged manner excluding patients with baseline dysarthria or ataxia or transient worsening of these symptoms following a unilateral procedure.
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13
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Niranjan A, Raju SS, Kooshkabadi A, Monaco E, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for essential tremor: Retrospective analysis of a 19-year experience. Mov Disord 2017; 32:769-777. [PMID: 28319282 DOI: 10.1002/mds.26925] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/29/2016] [Accepted: 12/23/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Essential Tremor (ET) is a common movement disorder that can be disabling. Initial treatment is in the form of medical therapies. Patients with medically refractory ET seek surgical intervention which include radiofrequency thalamotomy, deep brain stimulation, and radiosurgical thalamotomy. Radiosurgical thalamotomy is a minimally invasive surgical option which is especially valuable for elderly and high surgical risk patients. OBJECTIVE The purpose of this study was to retrospectively analyze the outcomes of stereotactic radiosurgery for patients suffering from medically refractory essential tremor. METHODS During a 19-year period (1996-2015), 73 patients underwent gamma knife thalamotomy for intractable essential tremor. A median central dose of 140 Gy (range, 130-150) was delivered to the nucleus ventralis intermedius through a single 4-mm isocenter. We used the Fahn-Tolosa-Marin clinical tremor rating scale to score tremor, handwriting, drawing, and ability to drink fluids. The median time to last follow-up was 28 months (range, 6-152). RESULTS After gamma knife thalamotomy, 93.2% improved in tremor. Forty-four patients (60.3%) experienced tremor arrest or barely perceptible tremor. Eighteen patients (24.7%) noted tremor arrest and complete restoration of motor function. Tremor improvement was sustained at last follow-up in 96% of patients who experience tremor relief. Mean tremor score improved from 3.19 before to 1.27 after gamma knife thalamotomy (P < 0.0001). Mean handwriting score improved from 2.97 to 1.25 (P < 0.0001). Mean drawing score improved from 3.16 to 1.26 (P < 0.0001). Mean drinking score improved from 3.14 to 1.56 (P < 0.0001). Imaging follow-up showed three types of lesions: enhancing lesion, streaking along internal capsule on fluid-attenuated inversion recovery, and significant reactive changes. Three patients (4%) experienced temporary adverse radiation effects. CONCLUSION Radiosurgery is a safe and valuable treatment option for medically refractory essential tremor, especially for the elderly or those with high surgical risk for DBS or radiofrequency thalamotomy. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sudesh S Raju
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ali Kooshkabadi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edward Monaco
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Gomes JGR, Gorgulho AA, de Oliveira López A, Saraiva CWC, Damiani LP, Pássaro AM, Salvajoli JV, de Oliveira Siqueira L, Salvajoli BP, De Salles AAF. The role of diffusion tensor imaging tractography for Gamma Knife thalamotomy planning. J Neurosurg 2016; 125:129-138. [DOI: 10.3171/2016.7.gks161553] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe role of tractography in Gamma Knife thalamotomy (GK-T) planning is still unclear. Pyramidal tractography might reduce the risk of radiation injury to the pyramidal tract and reduce motor complications.METHODSIn this study, the ventralis intermedius nucleus (VIM) targets of 20 patients were bilaterally defined using Iplannet Stereotaxy Software, according to the anterior commissure–posterior commissure (AC-PC) line and considering the localization of the pyramidal tract. The 40 targets and tractography were transferred as objects to the GammaPlan Treatment Planning System (GP-TPS). New targets were defined, according to the AC-PC line in the functional targets section of the GP-TPS. The target offsets required to maintain the internal capsule (IC) constraint of < 15 Gy were evaluated. In addition, the strategies available in GP-TPS to maintain the minimum conventional VIM target dose at > 100 Gy were determined.RESULTSA difference was observed between the positions of both targets and the doses to the IC. The lateral (x) and the vertical (z) coordinates were adjusted 1.9 mm medially and 1.3 mm cranially, respectively. The targets defined considering the position of the pyramidal tract were more medial and superior, based on the constraint of 15 Gy touching the object representing the IC in the GP-TPS. The best strategy to meet the set constraints was 90° Gamma angle (GA) with automatic shaping of dose distribution; this was followed by 110° GA. The worst GA was 70°. Treatment time was substantially increased by the shaping strategy, approximately doubling delivery time.CONCLUSIONSRoutine use of DTI pyramidal tractography might be important to fine-tune GK-T planning. DTI tractography, as well as anisotropy showing the VIM, promises to improve Gamma Knife functional procedures. They allow for a more objective definition of dose constraints to the IC and targeting. DTI pyramidal tractography introduced into the treatment planning may reduce the incidence of motor complications and improve efficacy. This needs to be validated in a large clinical series.
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Affiliation(s)
- João Gabriel Ribeiro Gomes
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
- 2Department of Neurosurgery, Real Hospital Português, Recife-PE, Brazil
| | - Alessandra Augusta Gorgulho
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | | | - Crystian Wilian Chagas Saraiva
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Lucas Petri Damiani
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Anderson Martins Pássaro
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - João Victor Salvajoli
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Ludmila de Oliveira Siqueira
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Bernardo Peres Salvajoli
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Antônio Afonso Ferreira De Salles
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
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Essential tremor: Update of therapeutic strategies (medical treatment and gamma knife thalamotomy). Rev Neurol (Paris) 2016; 172:408-415. [DOI: 10.1016/j.neurol.2016.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/06/2016] [Accepted: 07/25/2016] [Indexed: 11/18/2022]
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Higuchi Y, Matsuda S, Serizawa T. Gamma knife radiosurgery in movement disorders: Indications and limitations. Mov Disord 2016; 32:28-35. [DOI: 10.1002/mds.26625] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/29/2016] [Accepted: 03/02/2016] [Indexed: 11/09/2022] Open
Affiliation(s)
- Yoshinori Higuchi
- Department of Neurological Surgery; Chiba University Graduate School of Medicine; Chiba Japan
| | - Shinji Matsuda
- Department of Neurology and Strokology; Chiba Central Medical Center; Chiba Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center; Tsukiji Neurological Clinic; Tokyo Japan
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Lefranc M, Carron R, Regis J. Prelemniscal Radiations: A New Reliable Landmark of the Thalamic Nucleus Ventralis Intermedius Location? Stereotact Funct Neurosurg 2015; 93:400-6. [DOI: 10.1159/000441393] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/30/2015] [Indexed: 11/19/2022]
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Should we irradiate a brain tumor in a patient with parkinsonism? A case report and literature review. Pract Radiat Oncol 2015; 5:e327-35. [DOI: 10.1016/j.prro.2014.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/04/2014] [Accepted: 12/15/2014] [Indexed: 11/23/2022]
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Bötzel K, Tronnier V, Gasser T. The differential diagnosis and treatment of tremor. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:225-35; quiz 236. [PMID: 24739887 DOI: 10.3238/arztebl.2014.0225] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 01/15/2014] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Essential tremor is the most common type of tremor, with a prevalence of 0.4% in the overall population and 4-7% in persons over age 65. In general, tremor is so common that patients with tremor are frequently treated not only by neurologists, but also by physicians from other specialties. METHOD This review is based on publications retrieved by a selective PubMed search and on guidelines from Germany and abroad. RESULTS Particular tremor syndromes are usually diagnosed on the basis of their typical clinical presentation and whatever accompanying manifestations may be present. Ancillary tests are usually unnecessary. Unilateral rest tremor accompanied by rigidity and bradykinesia is typical of Parkinson's disease. Essential tremor is a bilateral postural tremor. The most common cause of intention tremor is multiple sclerosis. Mild tremor syndromes can often be treated satisfactorily with drugs. In case of severe tremor, which is rarer, a stereotactic operation can be considered. The usual outcome of such procedures is the complete suppression of tremor. CONCLUSION Most patients with tremor can be given a precise diagnosis and offered specific treatment. It is important for the physician to inform the patient about the expected course of tremor over time, its possible genetic causes, and the various available treatments.
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Affiliation(s)
- Kai Bötzel
- Department of Neurology, Institute for Clinical Neurosciences, Ludwig-Maximilians University of Munich, Klinikum Großhadern, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Department of Neurosurgery, German Center for Neurodegenerative Diseases, Tübingen University
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Gamma knife stereotactic radiosurgical thalamotomy for intractable tremor: A systematic review of the literature. Radiother Oncol 2015; 114:296-301. [DOI: 10.1016/j.radonc.2015.01.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/07/2015] [Accepted: 01/25/2015] [Indexed: 02/07/2023]
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21
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Bendersky D, Ajler P, Yampolsky C. [The use of neuromodulation for the treatment of tremor]. Surg Neurol Int 2014; 5:S232-46. [PMID: 25165613 PMCID: PMC4138824 DOI: 10.4103/2152-7806.137944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tremor may be a disabling disorder and pharmacologic treatment is the first-line therapy for these patients. Nevertheless, this treatment may lead to a satisfactory tremor reduction in only 50% of patients with essential tremor. Thalamotomy was the treatment of choice for tremor refractory to medical therapy until deep brain stimulation (DBS) of the ventral intermedius nucleus (Vim) of the thalamus has started being used. Nowadays, thalamotomy is rarely performed. METHODS This article is a non-systematic review of the indications, results, programming parameters and surgical technique of DBS of the Vim for the treatment of tremor. RESULTS In spite of the fact that it is possible to achieve similar clinical results using thalamotomy or DBS of the Vim, the former causes more adverse effects than the latter. Furthermore, DBS can be used bilaterally, whereas thalamotomy has a high risk of causing disartria when it is performed in both sides. DBS of the Vim achieved an adequate tremor improvement in several series of patients with tremor caused by essential tremor, Parkinson's disease or multiple sclerosis. Besides the Vim, there are other targets, which are being used by some authors, such as the zona incerta and the prelemniscal radiations. CONCLUSION DBS of the Vim is a useful treatment for disabling tremor refractory to medical therapy. It is essential to carry out an accurate patient selection as well as to use a proper surgical technique. The best stereotactic target for tremor is still unknown, although the Vim is the most used one.
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Affiliation(s)
- Damián Bendersky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Claudio Yampolsky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Willingness-to-Accept Gamma Knife Radiosurgery for Tinnitus Among Career San Francisco Firefighters. Otol Neurotol 2014; 35:1026-32. [DOI: 10.1097/mao.0000000000000312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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24
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[Stereotactic radiosurgery for movement disorders]. Neurol Neurochir Pol 2012; 46:52-62. [PMID: 22426763 DOI: 10.5114/ninp.2012.27449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nowadays, functional neurosurgery is an established treatment for movement disorders such as Parkinson's disease, essential tremor, and dystonia. The effectiveness and safety of neuromodulation procedures (deep brain stimulation) replaced in the last years ablative irreversible stereotactic lesions for movement disorders. Stereotactic radiosurgery with gamma knife is a non-invasive form of treatment for movement disorders. The main limitation of stereotactic radiosurgery is the impossibility of electrophysiological confirmation of the target structure. Nevertheless, patients with advanced age and significant medical conditions that preclude classic open stereotactic procedures or patients who must receive anticoagulation therapy may gain great functional benefit using gamma knife stereotactic radiosurgery.
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Kondziolka D, Flickinger JC, Niranjan A, Lunsford LD. Trends and importance of radiosurgery for the development of functional neurosurgery. Surg Neurol Int 2012; 3:S3-9. [PMID: 22826808 PMCID: PMC3400481 DOI: 10.4103/2152-7806.91604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/20/2011] [Indexed: 11/29/2022] Open
Abstract
Functional neurosurgery includes surgery conducted to ablate, augment, or modulate targets that lead to improvement in neurological function or behavior. Surgical approaches for this purpose include destructive lesioning with different mechanical or biologic agents or energy sources, non-destructive electrical modulation, and cellular or chemical augmentation. Our purpose was to review the role of stereotactic radiosurgery used for functional indications and to discuss future applications and potential techniques. Imaging and neurophysiological research will enable surgeons to consider new targets and circuits that may be clinically important. Radiosurgery is one minimal access approach to those targets.
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Affiliation(s)
- Douglas Kondziolka
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John C. Flickinger
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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26
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Frighetto L, Bizzi J, Annes RD, Silva RDS, Oppitz P. Stereotactic radiosurgery for movement disorders. Surg Neurol Int 2012; 3:S10-6. [PMID: 22826805 PMCID: PMC3400484 DOI: 10.4103/2152-7806.91605] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 12/21/2011] [Indexed: 11/18/2022] Open
Abstract
Initially designed for the treatment of functional brain targets, stereotactic radiosurgery (SRS) has achieved an important role in the management of a wide range of neurosurgical pathologies. The interest in the application of the technique for the treatment of pain, and psychiatric and movement disorders has returned in the beginning of the 1990s, stimulated by the advances in neuroimaging, computerized dosimetry, treatment planning software systems, and the outstanding results of radiosurgery in other brain diseases. Since SRS is a neuroimaging-guided procedure, without the possibility of neurophysiological confirmation of the target, deep brain stimulation (DBS) and radiofrequency procedures are considered the best treatment options for movement-related disorders. Therefore, SRS is an option for patients who are not suitable for an open neurosurgical procedure. SRS thalamotomy provided results in tremor control, comparable to radiofrequency and DBS. The occurrence of unpredictable larger lesions than expected with permanent neurological deficits is a limitation of the procedure. Improvements in SRS technique with dose reduction, use of a single isocenter, and smaller collimators were made to reduce the incidence of this serious complication. Pallidotomies performed with radiosurgery did not achieve the same good results. Even though the development of DBS has supplanted lesioning as the first alternative in movement disorder surgery; SRS might still be the only treatment option for selected patients.
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Affiliation(s)
- Leonardo Frighetto
- Neurosurgeon of the Neurology and Neurosurgery Service, Stereotactic Radiosurgery Section, Moinhos de Vento Hospital, Porto Alegre, São Vicente de Paulo University Hospital, Passo Fundo, RS, Brazil
- Neurosurgeon, São Vicente de Paulo University Hospital, Passo Fundo, RS, Brazil
| | - Jorge Bizzi
- Neurosurgeon of the Neurology and Neurosurgery Service, Stereotactic Radiosurgery Section, Moinhos de Vento Hospital, Porto Alegre, São Vicente de Paulo University Hospital, Passo Fundo, RS, Brazil
| | | | | | - Paulo Oppitz
- Neurosurgeon of the Neurology and Neurosurgery Service, Stereotactic Radiosurgery Section, Moinhos de Vento Hospital, Porto Alegre, São Vicente de Paulo University Hospital, Passo Fundo, RS, Brazil
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Ohye C, Higuchi Y, Shibazaki T, Hashimoto T, Koyama T, Hirai T, Matsuda S, Serizawa T, Hori T, Hayashi M, Ochiai T, Samura H, Yamashiro K. Gamma Knife Thalamotomy for Parkinson Disease and Essential Tremor: A Prospective Multicenter Study. Neurosurgery 2011; 70:526-35; discussion 535-6. [DOI: 10.1227/neu.0b013e3182350893] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
No prospective study of gamma knife thalamotomy for intractable tremor has previously been reported.
Objective:
To clarify the safety and optimally effective conditions for performing unilateral gamma knife (GK) thalamotomy for tremors of Parkinson disease (PD) and essential tremor (ET), a systematic postirradiation 24-month follow-up study was conducted at 6 institutions. We present the results of this multicenter collaborative trial.
Methods:
In total, 72 patients (PD characterized by tremor, n = 59; ET, n = 13) were registered at 6 Japanese institutions. Following our selective thalamotomy procedure, the lateral part of the ventralis intermedius nucleus, 45% of the thalamic length from the anterior tip, was selected as the GK isocenter. A single 130-Gy shot was applied using a 4-mm collimator. Evaluation included neurological examination, magnetic resonance imaging and/or computerized tomography, the unified Parkinson's disease rating scale (UPDRS), electromyography, medication change, and video observations.
Results:
Final clinical effects were favorable. Of 53 patients who completed 24 months of follow-up, 43 were evaluated as having excellent or good results (81.1%). UPDRS scores showed tremor improvement (parts II and III). Thalamic lesion size fluctuated but converged to either an almost spherical shape (65.6%), a sphere with streaking (23.4%), or an extended high-signal zone (10.9%). No permanent clinical complications were observed.
Conclusion:
GK thalamotomy is an alternative treatment for intractable tremors of PD as well as for ET. Less invasive intervention may be beneficial to patients.
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Affiliation(s)
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toru Shibazaki
- Functional and Gamma Knife Surgery Center, Hidaka Hospital, Takasaki, Japan
| | - Takao Hashimoto
- Center for Neurological Diseases, Aizawa Hospital, Matsumoto, Japan
| | - Toru Koyama
- Center for Neurological Diseases, Aizawa Hospital, Matsumoto, Japan
| | - Tatsuo Hirai
- Gamma Knife Center, Heisei Memorial Hospital, Fujieda, Japan
| | - Shinji Matsuda
- Gamma Knife House, Chiba Cardiovascular Center, Ichihara, Japan
| | - Toru Serizawa
- Gamma Knife House, Chiba Cardiovascular Center, Ichihara, Japan
| | - Tomokatsu Hori
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Taku Ochiai
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirofumi Samura
- Department of Neurosurgery, Okinawa Central Hospital, Naha, Japan
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Franzini A, Marchetti M, Brait L, Milanesi I, Messina G, Forapani E, Broggi G, Fariselli L. Deep brain stimulation and frameless stereotactic radiosurgery in the treatment of bilateral parkinsonian tremor: target selection and case report of two patients. Acta Neurochir (Wien) 2011; 153:1069-75. [PMID: 21336920 DOI: 10.1007/s00701-011-0962-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 01/31/2011] [Indexed: 10/18/2022]
Abstract
Considerable positive experience in functional radiosurgery has been reported since Leksell's first experience in 1951, but the development of frameless radiosurgery was been limited because of the difficulty of identifying invisible functional targets. In this paper we report on two cases of bilateral parkinsonian tremor successfully treated with DBS on one side and with frameless radiosurgery on the contralateral side. We focus on the methodology developed to define the three-dimensional target coordinates for frameless radiosurgery. Two patients suffering from a disabling upper-limb parkinsonian tremor underwent frameless radiosurgical thalamotomy. To accurately identify the treatment target the CT gantry was treated as a stereotactic frame; a rototranslation between the origin of the screen and the origin of the stereotactic atlas allowed us to obtain atlas-registered 3D coordinates of each point on the CT axial brain slices. Both patients achieved complete bilateral tremor control by unilateral radiosurgery and contralateral DBS. We developed a method for determining the 3D coordinates of a known functional target to treat with frameless radiosurgery. Based on the initial experiences, frameless radiosurgery appears to be an alternative treatment for Parkinsonian upper limb tremor in the presence of increased surgical risks for DBS placement.
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Barbarisi M, Pantelis E, Antypas C, Romanelli P. Radiosurgery for movement disorders. COMPUTER AIDED SURGERY : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR COMPUTER AIDED SURGERY 2011; 16:101-111. [PMID: 21476787 DOI: 10.3109/10929088.2011.569127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Stereotactic radiosurgery (SRS) has been proposed as an alternative treatment modality to pharmaceutical administration and deep brain stimulation (DBS) for patients suffering from movement disorders. Advanced neuroimaging is required for the identification of the functional structures and the accurate placement of the SRS lesion within the brain. Atlas-based techniques have also been used to aid delineation of the target during treatment planning. Maximum doses greater than 120 Gy have been suggested for controlling movement disorders. These high delivered doses and the irreversible character of SRS require accurate placement of the created lesions. In this article, achievements in the field of stereotactic radiosurgery, neuroimaging, and radiosurgical dose planning are reviewed, and an overview is provided of the clinical experience obtained to date in the radiosurgical treatment of movement disorders.
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Affiliation(s)
- Manlio Barbarisi
- Functional Neurosurgery Department, IRCCS Neuromed, Pozzilli, Italy
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Radiosurgery scope of practice in Canada: A report of the Canadian association of radiation oncology (CARO) radiosurgery advisory committee. Radiother Oncol 2010; 95:122-8. [DOI: 10.1016/j.radonc.2010.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 01/07/2010] [Indexed: 11/20/2022]
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Mathieu D, Kondziolka D, Niranjan A, Flickinger J, Lunsford LD. Gamma knife thalamotomy for multiple sclerosis tremor. ACTA ACUST UNITED AC 2007; 68:394-9. [PMID: 17905063 DOI: 10.1016/j.surneu.2006.11.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Accepted: 11/14/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Some patients with MS suffer from disabling tremor. Improvement with medical treatment is modest, at best. Stereotactic surgery targeting the vim nucleus of the thalamus has been successful in alleviating MS tremor. Gamma knife radiosurgery represents a minimally invasive alternative to radiofrequency lesioning and DBS that can provide improvement in patients suffering from essential and parkinsonian tremor. We reviewed our experience with GK thalamotomy in the management of six consecutive patients suffering from disabling MS tremor. METHODS The median age at the time of radiosurgery was 46 years (range, 31 to 57 years). Intention tremor had been present for a median of three years (range 8 months to 12 years). One 4-mm isocenter was used to deliver a median maximum dose of 140 Gy (range, 130-150 Gy) to the vim nucleus of the thalamus opposite the side of the most disabling tremor. Clinical outcome was assessed using the Fahn-Tolosa-Marin scale. RESULTS The median follow-up was 27.5 months (range, 5-46 months). All patients experienced improvement in tremor after a median latency period of 2.5 months. More improvement was noted in tremor amplitude than in writing and drawing ability. In four patients, the tremor reduction led to functional improvement. One patient suffered from transient contralateral hemiparesis, which resolved after brief corticosteroid administration. No other complication was seen. CONCLUSION Gamma knife radiosurgical thalamotomy is effective as a minimally invasive alternative to stereotactic surgery for the palliative treatment of disabling MS tremor.
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Affiliation(s)
- David Mathieu
- Department of Neurological Surgery, University of Pittsburgh, Center for Image-Guided Neurosurgery, Pittsburgh, PA 15213, USA
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Rabinov JD, Cheng LL, Lee PL, Brisman JL, Loeffler JS, Cole AJ, Cosgrove GR, Bussiere MR, Chaves T, Gonzalez RG. MR Spectroscopic Changes in the Rat Hippocampus following Proton Radiosurgery. Stereotact Funct Neurosurg 2006; 84:147-54. [PMID: 16899979 DOI: 10.1159/000094862] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To identify MR spectroscopic changes in the rat hippocampus following proton radiosurgery. METHODS AND MATERIALS A group of 12 rats were treated with Bragg peak proton beam irradiation involving the right hippocampus. Single doses of 30 CGE, 50 CGE, 70 CGE, 90 CGE were delivered to groups of 3 animals using single fraction technique. Animals were imaged using a standard 3 T GE Signa MRI at 4 months following treatment. An untreated animal was also studied. A 3'' surface coil was employed to obtain T1 weighted coronal pre- and post-gadolinium images (TR 600 and TE 30) and dual echo T2 weighted coronal images (TR 3000, TE 30/90). Volumetric analysis with custom software was done to evaluate areas of increased signal on T2 weighted images and the development of hydrocephalus was examined. Animals were sacrificed and specimens of the treated hippocampus were harvested for High Resolution Magic Angle Spinning MR Spectroscopy (HRMAS) followed by histopathology of the tissue samples. Peak values of choline, creatine, N-acetyl aspartate and lipids were evaluated and compared. RESULTS Peak tissue injury occurred in the surviving 90 CGE animal by both T2 weighted and post-gadolinium imaging. Gadolinium enhancement was seen in decreasing volumes of tissue at dosage levels from 90 to 50 CGE. Hydrocephalus was seen on the untreated side in the 90 CGE animal likely because of mass effect, while it was seen in small degrees in the side of treatment in the 70 and 50 CGE animals. Histopathology showed changes at 90 and 70 CGE, but not at 50 or 30 CGE at this time point using H and E stains. HRMAS showed spectroscopic changes in the surviving 90 and 70 CGE animals but not in the 50 and 30 CGE animals. Statistical significance was not reached because of the small sample size. CONCLUSIONS Following single dose proton radiosurgery of rat hippocampus, HRMAS is able to identify metabolic changes induced by radiation. Studies built on these principles may help develop non-invasive MR spectroscopic methods to distinguish radiation changes from tumor recurrence.
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Affiliation(s)
- J D Rabinov
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Sato S, Ohye C, Shibazaki T, Zama A, Cai X. Neurophysiological Evaluation of the Optimum Target in Gamma Thalamotomy: Indirect Evidence. Stereotact Funct Neurosurg 2005; 83:108-12; discussion 113-4. [PMID: 16088291 DOI: 10.1159/000087307] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Gamma thalamotomy has been useful for the treatment of Parkinson's disease and other movement disorders, but it has disadvantages, such as a delayed clinical effect after irradiation and the inaccuracy of targeting because depth recording is not available. Therefore, we sought to determine the optimum target in gamma thalamotomy based on the results of conventional selective thalamotomy with reference to the AC-PC line. To obtain indirect support for the appropriateness of the optimum target, we performed depth recording around the region of the estimated optimum target based on the results of conventional thalamotomy. Four patients with tremor caused by Parkinson's disease or essential tremor were used as subjects after they gave their fully informed consent. The targets were determined as points 6-8 mm anterior to the posterior commissure, 4-6 mm dorsal to the level of the intercommissural line, and 15-17 mm lateral from the midline. Rhythmic discharge time-locked to tremor and/or kinesthetic neurons were found within the expected target area in all patients. Finally, in all cases, the tremor was abolished without complications after coagulative lesions were made with dual coagulation needles to cover the supposed Vim zone according to the depth recording. We considered that the target point determined in the same way as in gamma thalamotomy is suitable from an anatomophysiological perspective.
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Affiliation(s)
- Sumito Sato
- Functional and Gamma Knife Surgery Center, Hidaka Hospital, Takasaki, Gunma, Japan.
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Ohye C, Shibazaki T, Sato S. Gamma knife thalamotomy for movement disorders: evaluation of the thalamic lesion and clinical results. J Neurosurg 2005. [DOI: 10.3171/sup.2005.102.s_supplement.0234] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The authors studied the effects of gamma knife thalamotomy (GKT) on Parkinson disease-related tremor and essential tremor before and after reloading of radioactive cobalt.
Methods. Based on experience in stereotactic thalamotomy aided by depth microrecording, the target was located at the lateral border of the thalamic ventralis intermedius nucleus (VIM). For more precise targeting, the percentage representation of the thalamic VIM in relation to the entire thalamic length is useful. The location of the target was determined on magnetic resonance (MR) imaging and computerized tomography scanning. A maximum dose of 130 Gy was delivered to the target by using a single isocenter with the 4-mm collimator. In more recent cases, a systematic follow-up examination was performed at 3, 6, 12, 18, and 24 months after GKT.
Since 1993, the authors have treated 70 patients with PD. Throughout the series the same dosimetric technique has been used. The course after GKT was compared between the 25 cases with PD treated before reloading and the 35 cases treated after reloading. In the majority (80–85%) treated after reloading, tremor and rigidity were reduced around 6 months after GKT. In the cases treated before reloading this effect took approximately 1 year. The thalamic reaction on MR imaging showed the same two lesion types in both series: a restricted and a diffuse. After reloading the restricted lesion was more frequent and the lesion volume was smaller.
Conclusions. The shorter delay in clinical improvement and smaller lesion size may be related to an increased radiation dose.
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Ohye C, Shibazaki T, Sato S. Gamma knife thalamotomy for movement disorders: evaluation of the thalamic lesion and clinical results. J Neurosurg 2005; 102 Suppl:234-40. [PMID: 15662817 DOI: 10.3171/jns.2005.102.s_supplement.0234] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object.The authors studied the effects of gamma knife thalamotomy (GKT) on Parkinson disease-related tremor and essential tremor before and after reloading of radioactive cobalt.Methods.Based on experience in stereotactic thalamotomy aided by depth microrecording, the target was located at the lateral border of the thalamic ventralis intermedius nucleus (VIM). For more precise targeting, the percentage representation of the thalamic VIM in relation to the entire thalamic length is useful. The location of the target was determined on magnetic resonance (MR) imaging and computerized tomography scanning. A maximum dose of 130 Gy was delivered to the target by using a single isocenter with the 4-mm collimator. In more recent cases, a systematic follow-up examination was performed at 3, 6, 12, 18, and 24 months after GKT.Since 1993, the authors have treated 70 patients with PD. Throughout the series the same dosimetric technique has been used. The course after GKT was compared between the 25 cases with PD treated before reloading and the 35 cases treated after reloading. In the majority (80–85%) treated after reloading, tremor and rigidity were reduced around 6 months after GKT. In the cases treated before reloading this effect took approximately 1 year. The thalamic reaction on MR imaging showed the same two lesion types in both series: a restricted and a diffuse. After reloading the restricted lesion was more frequent and the lesion volume was smaller.Conclusions.The shorter delay in clinical improvement and smaller lesion size may be related to an increased radiation dose.
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Affiliation(s)
- Chihiro Ohye
- Functional and Gamma Knife Surgery Center, Hidaka Hospital, Gunma, Japan.
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Rabinov JD, Brisman JL, Cole AJ, Lee PL, Bussiere MR, Chapman PH, Loeffler JS, Cosgrove GR, Chaves T, Gonzalez RG. MRI Changes in the Rat Hippocampus following Proton Radiosurgery. Stereotact Funct Neurosurg 2004; 82:156-64. [PMID: 15499227 DOI: 10.1159/000081639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To define radiographic dose-response relationships for proton radiosurgery using a rat brain model. METHODS AND MATERIALS A group of 23 rats was treated with Bragg peak proton beam irradiation involving the right hippocampus. Single doses of 5, 12, 20, 30, 60, 90 and 130 cobalt gray equivalents (CGE) were delivered to groups of 3 animals using single fraction technique. One extra animal was included at the 130- and 30-CGE doses. Animals were imaged using a standard 1.5-tesla GE Signa MRI. A 3-inch surface coil was employed to obtain T1-weighted sagittal images (TR 600 and TE 30) and dual echo T2-weighted coronal images (TR 3,000 and TE 30/90). Animals were imaged at 1.5, 3, 4.5, 6 and 9 months. Volumetric analysis with custom software was done to evaluate areas of increased signal on T2-weighted images, and signal change versus time curves were generated. Gadolinium-enhanced T1-weighted imaging was also done at the 9-month time point to further evaluate tissue injury. The development of hydrocephalus was also examined. RESULTS Peak tissue injury was greater and occurred earlier with higher versus lower doses of radiation. Statistically significant differences were seen between the 130- and 90-CGE animals and between the 90- and 60-CGE animals (p < 0.0016) using ANOVA. Signal changes can be seen in at least 1 of the animals at 20 CGE. The largest volume of tissue enhancement at 9 months was seen in animals at 60 CGE, which may represent an intermediate zone of tissue injury and gliosis compared with greater tissue loss at higher doses and less injury at lower doses. Hydrocephalus developed first in the untreated hemisphere in 130- and 90-CGE animals as a result of mass effect while it occurred at a later time in the treated hemisphere in lower-dose animals. CONCLUSIONS Following single-dose proton radiosurgery of rat hippocampus, serial MRIs show T2 signal changes in animals ranging from 130 down to 20 CGE as well as the development of hydrocephalus. Dose-effect relationships using proton radiosurgery in rats will be a helpful step in guiding further studies on radiation injury to brain tissue.
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Affiliation(s)
- James D Rabinov
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Frighetto L, De Salles A, Wallace R, Ford J, Selch M, Cabatan-Awang C, Solberg T. Linear accelerator thalamotomy. ACTA ACUST UNITED AC 2004; 62:106-13; discussion 113-4. [PMID: 15261496 DOI: 10.1016/j.surneu.2003.08.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2003] [Accepted: 08/26/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND The capability of performing functional radiosurgery lesions in the brain using a dedicated linear accelerator (LINAC) have not yet been demonstrated. This study evaluates modern LINAC technology for the creation of a sharp, small and functionally eloquent lesion in the thalamus. METHODS Three patients underwent thalamotomy using a dedicated linear accelerator to radiosurgery, 2 females and 1 male, ages were 52, 53, and 73 years. Two patients presented with unilateral poststroke central pain and 1 with unilateral upper extremity pain secondary to metastatic infiltration of the brachial plexus. Maximal doses varied from 150 to 200 Gy, delivered by a 5-mm diameter collimator and 5 to 8 noncoplanar arcs evenly distributed. RESULTS All patients gained substantial relief of their pain. They were able to reduce their medications and improve their activity levels. The patient with end-stage metastatic disease died of his malignancy 2 weeks after the treatment. One patient presented with recurrence of the pain 4 months after the treatment. No clinical complications were noticed. CONCLUSIONS A dedicated linear accelerator is able to perform a precise and circumscribed lesion in the thalamus for pain control. Moreover, it proved to be safe, because no complications were observed. For patients using chronic anticoagulant therapy or with severe disabilities caused by cardiac, pulmonary or malignant diseases, this technique represents an alternative of treatment to radiofrequency thalamotomy.
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Affiliation(s)
- Leonardo Frighetto
- Division of Neurosurgery, School of Medicine, University of California-Los Angeles Medical Center, 200 UCLA Medical Plaza, Los Angeles, CA 90095-7182, USA
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Okun MS, Vitek JL. Lesion therapy for Parkinson's disease and other movement disorders: Update and controversies. Mov Disord 2004; 19:375-89. [PMID: 15077235 DOI: 10.1002/mds.20037] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An analysis of the international literature on lesioning for movement disorders was undertaken to review lesion therapy for Parkinson's disease (PD) and other movement disorders and to highlight important controversies surrounding this surgical technique. Lesions have been placed throughout the neuraxis with varying approaches and success. Our understanding of the pathophysiological basis underlying the development of PD and other movement disorders has led to a better understanding of why lesioning certain portions of the nervous system should improve motor function. Advances in imaging technology and electrophysiological techniques used for localization of brain structures, such as microelectrode mapping, have improved the ability to accurately identify and lesion target structures deep in the brain. This improvement has led to an increase in the degree and consistency of clinical benefit. The major controversies in lesion therapy include: (1) which target for which disorder; (2) determination of the optimal lesion site and whether the external globus pallidus (GPe) should be included in the pallidotomy lesion for PD; (3) determination of the size of the lesion; (4) whether bilateral lesions can be placed without the high incidence of side effects reported by some investigators; (5) whether microelectrodes aid in the ability to improve clinical outcomes or increase the risk of side effects by making multiple microelectrode penetrations; (6) whether the subthalamic nucleus (STN) should be explored further as a lesioning target; and (7) whether lesioning should be abandoned entirely in favor of deep brain stimulation (DBS). Many important questions and controversies regarding lesion therapy remain unanswered. It is unlikely given the pro-DBS environment that these questions will be answered in the near future. We should, however, be careful not to abandon an effective therapy before fully exploring through randomized trials the relative effect of different surgical approaches for the treatment of patients with movement disorders.
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Affiliation(s)
- Michael S Okun
- Department of Neurology, University of Florida, Gainesville, Florida, USA.
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López-Flores G, Miguel-Morales J, Teijeiro-Amador J, Vitek J, Perez-Parra S, Fernández-Melo R, Maragoto C, Alvarez E, Alvarez L, Macías R, Obeso JA. Anatomic and neurophysiological methods for the targeting and lesioning of the subthalamic nucleus: Cuban experience and review. Neurosurgery 2003; 52:817-30; discussion 831. [PMID: 12657177 DOI: 10.1227/01.neu.0000053224.16728.7d] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2002] [Accepted: 11/11/2002] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To develop a method to place a lesion precisely in the subthalamic nucleus (STN) and evaluate its effectiveness. METHODS A retrospective study of targeting data collected during stereotactic planning to lesion the STN in 31 patients with Parkinson's disease and of results in more than 50 procedures was performed. The targeting method was based on computed tomographic imaging together with semimicroelectrode recording digital processing and electrical stimulation. Two statistical methods were used to correlate initial with final target coordinates and assess the efficacy of the targeting procedure. RESULTS The anatomic target based on computed tomographic imaging data showed electrical activity in the subthalamus in the first pass in 82% of the procedures. In the remaining 18%, the STN was an average of 1.93 mm away from the nearest trajectory that recorded the STN (range, 1.41-2.24 mm). The average number of trajectories per procedure was 7.2; the location of the first trajectory relative to the center of the nucleus determined by electrical and physiological means (P < 0.01, analysis of variance, Student's t test) was as follows: in the lateral direction, 1.25 +/- 1.15 mm; in the anteroposterior direction, 1.53 +/- 1.31 mm; and in the vertical direction, 0.67 +/- 0.51 mm. The average number of tracts necessary to lesion the STN was two. CONCLUSION The combination of computed tomographic imaging, semimicroelectrode recording, and microstimulation provides an effective method to identify the STN lesion in parkinsonian patients. The method used for anatomic localization and electrophysiological mapping of the subthalamus was found to be effective in reaching the sensorimotor region of the nucleus. We carried out an accurate determination of the subthalamus location and its volume in the lesioning.
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Affiliation(s)
- Gerardo López-Flores
- Department of Neurosurgery and Motor Disorders Clinic, Centro Internacional de Restauración Neurológica, Havana, Cuba.
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Keep MF, Mastrofrancesco L, Erdman D, Murphy B, Ashby LS. Gamma knife subthalamotomy for Parkinson disease: the subthalamic nucleus as a new radiosurgical target. J Neurosurg 2002. [DOI: 10.3171/jns.2002.97.supplement_5.0592] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ The authors present the neuroimaging, treatment planning, and radiosurgical technique for the first reported case of unilateral radiosurgical subthalamotomy, which was performed to control motor symptoms associated with advanced Parkinson disease (PD) in a patient who had undergone previous contralateral radiofrequency (RF) pallidotomy.
A 73-year-old woman with end-stage PD had undergone RF pallidotomy of the right globus pallidus with resolution of symptoms. Two years following this procedure, due to the natural progression of her disease, she suffered recurrent motor fluctuations, dyskinesia, and worsening bradykinesia of the right side. Her Parkinson's Disease Disability Rating (PDDR) score was 28. Computerized tomography and magnetic resonance (MR) imaging were used to localize the left subthalamic nucleus (STN). The patient underwent gamma knife radiosurgery—a single shot of 120 Gy was administered using the 4-mm collimator helmet.
The patient was evaluated up to 42 months after the procedure. The dyskinesia became minimal. Right-sided motor control improved as did her balance. At 3 months after treatment MR imaging demonstrated the radiosurgical lesion in the left STN. At 3.5 years postradiosurgery, she experienced minimal focal (oral) dyskinesia, no bradykinesia or rigidity, and her PDDR score was 11.
Radiosurgery of the STN in this case was safe and effective. The STN is a readily localized anatomical target with neuroimaging. Radiosurgery avoids the risks of open procedures.
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De Salles AA, Melega WP, Laćan G, Steele LJ, Solberg TD. Radiosurgery performed with the aid of a 3-mm collimator in the subthalamic nucleus and substantia nigra of the vervet monkey. J Neurosurg 2001; 95:990-7. [PMID: 11765845 DOI: 10.3171/jns.2001.95.6.0990] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Radiosurgery for functional neurosurgery performed using a linear accelerator (LINAC) has not been extensively characterized in preclinical studies. In the present study, the properties of a newly designed 3-mm-diameter collimator were evaluated in a dedicated LINAC, which produced lesions in the basal ganglia of vervet monkeys. Lesion formation was determined in vivo in three animals by examining magnetic resonance (MR) images to show the dose-delivery precision of targeting and the geometry and extent of the lesions. Postmortem immunohistochemical studies were conducted to determine the extent of lesion-induced radiobiological effects. METHODS In three male vervet monkeys, the subthalamic nucleus (STN; one animal) and the pars compacta of the lateral substantia nigra (SN; two animals) were targeted by a Novalis Shaped Beam Surgery System that included a 3-mm collimator and delivered a maximum dose of 150 Gy. Magnetic resonance images obtained 4, 5, and 9 months posttreatment were reviewed, and the animals were killed so that immunohistological characterizations could be made. CONCLUSIONS The generation of precise radiosurgical lesions by a 3-mm collimator was validated in studies that targeted the basal ganglia of the vervet monkey. The extent of the lesions created in all animals remained restricted in diameter (< 3 mm) throughout the duration of the studies, as assessed by reviewing MR images. Histological studies showed that the lesions were contained within the STN and SN target areas and that there were persistent increases in glial fibrillary acidic protein immunoreactivity. Increases in immunoreactivity for tyrosine hydroxylase, the serotonin transporter, and the GluR1 subunit of the alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate glutamate receptor in penumbral regions of the lesion were suggestive of compensatory neuronal adaptations. This radiosurgical approach may be of particular interest for the induction of lesions of the STN and SN in studies of experimental parkinsonism, as well as for the development of potential radiosurgical treatments for Parkinson disease.
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Affiliation(s)
- A A De Salles
- Department of Surgery, University of California at Los Angeles School of Medicine, California 90095-6975, USA.
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Siderowf A, Gollump SM, Stern MB, Baltuch GH, Riina HA. Emergence of complex, involuntary movements after gamma knife radiosurgery for essential tremor. Mov Disord 2001; 16:965-7. [PMID: 11746633 DOI: 10.1002/mds.1178] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Gamma knife radiosurgery is generally considered a safer alternative to traditional pallidotomy or thalamotomy. We report the case of a 59-year-old patient with essential tremor who developed a complex, disabling movement disorder following gamma knife thalamotomy. This case illustrates the need for long-term follow-up to fully evaluate the potential for complications following radiosurgery.
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Affiliation(s)
- A Siderowf
- Department of Neurology, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Young RF, Jacques S, Mark R, Kopyov O, Copcutt B, Posewitz A, Li F. Gamma knife thalamotomy for treatment of tremor: long-term results. J Neurosurg 2000. [DOI: 10.3171/jns.2000.93.supplement_3.0128] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The purpose of this study was to investigate the long-term effects of gamma knife thalamotomy for treatment of disabling tremor.
Methods. One hundred fifty-eight patients underwent magnetic resonance imaging—guided radiosurgical nucleus ventralis intermedius (VIM) thalamotomy for the treatment of parkinsonian tremor (102 patients), essential tremor (52 patients), or tremor due to stroke, encephalitis, or cerebral trauma (four patients). Preoperative and postoperative blinded assessments were performed by a team of independent examiners skilled in the evolution of movement disorders. A single isocenter exposure with the 4-mm collimator helmet of the Leksell gamma knife unit was used to make the lesions.
In patients with Parkinson's disease 88.3% became fully or nearly tremor free, with a mean follow up of 52.5 months. Statistically significant improvements were seen in Unified Parkinson's Disease Rating Scale tremor scores and rigidity scores, and these improvements were maintained in 74 patients followed 4 years or longer.
In patients with essential tremor, 92.1% were fully or nearly tremor free postoperatively, but only 88.2% remained tremor free by 4 years or more post-GKS. Statistically significant improvements were seen in the Clinical Rating Scale for tremor in essential tremor patients and these improvements were well maintained in the 17 patients, followed 4 years or longer. Only 50% of patients with tremor of other origins improved significantly.
One patient sustained a transient complication and two patients sustained mild permanent side effects from the treatments.
Conclusions. Gamma knife VIM thalamotomy provides relief from tremor equivalent to that provided by radiofrequency thalamotomy or deep brain stimulation, but it is safer than either of these alternatives. Long-term follow up indicates that relief of tremor is well maintained. No long-term radiation-induced complications have been observed.
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Niemann K, Mennicken VR, Jeanmonod D, Morel A. The Morel stereotactic atlas of the human thalamus: atlas-to-MR registration of internally consistent canonical model. Neuroimage 2000; 12:601-16. [PMID: 11112393 DOI: 10.1006/nimg.2000.0650] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In 1997, Morel, Magnin, and Jeanmonod presented a microscopic stereotactic atlas of the human thalamus. Parcellations of thalamic nuclei did not only use cyto- and myeloarchitectonic criteria, but were additionally corroborated by staining for calcium-binding proteins, which bears functional significance. The atlas complies with the Anglosaxon nomenclature elaborated by Jones and the data were sampled in three orthogonal planes in the AC-PC reference space. We report on the generation of three-dimensional digital models of the thalamus based on the three sets of sections (sagittal, horizontal, and frontal). Spatial differences between the three anatomical specimens were evaluated using the centers of gravity of 13 selected nuclei as landmarks. Subsequent linear regression analysis yielded equations, which were used to normalize the frontal and horizontal digital models to the sagittal one. The outcome is an internally consistent Canonical Model of Morel's atlas, which minimizes the linear component of the variability between the three sectioned anatomical specimens. In addition, we demonstrate the feasibility of the atlas-to-MRI registration in conjunction with on-line visualization of the trajectory in the digital models.
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Affiliation(s)
- K Niemann
- Institute of Anatomy and Clinical Morphology, University of Witten/Herdecke, Witten, Germany.
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Abstract
Surgical treatment of Parkinson's disease (PD) can provide gratifying symptomatic improvements for many individuals who suffer from persistent disabling symptoms despite the best available medical management. Current surgical therapies include ablative techniques (thalamotomy and pallidotomy), augmentative techniques (nondestructive) (deep brain stimulation), and restorative techniques (tissue transplantation and gene therapy). Ablative procedures can provide substantial clinical benefit, but the current trend is toward deep brain stimulation, which can provide similar symptomatic improvement in a nondestructive manner. Restorative techniques, such as tissue transplantation and gene therapy, are exciting but have significant obstacles to overcome before their promise can be realized. Until the underlying pathological defect of PD can be identified and treated, surgical intervention is likely to remain important in the symptomatic treatment of this disabling disease.
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Affiliation(s)
- K A Follett
- Division of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.
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Abstract
Parkinson's disease is a neurodegenerative disorder that manifests clinically with variable degrees of tremor, muscle rigidity, bradykinesia and postural instability. Tremor-predominant Parkinson's disease is characterised by prominent tremor of one or more limbs with a relative lack of significant rigidity and bradykinesia. Despite the lack of other disabling motor symptoms, the tremor of tremor-predominant Parkinson's disease can be very disabling, especially if a postural and kinetic component exists. A wide variety of treatments for Parkinson's disease tremor are currently available and include use of oral medications, injections with botulinum toxin and neurosurgical procedures. Some of the first line medications (levodopa, dopamine agonists, anticholinergics) are very effective in controlling tremor. However, some patients with Parkinson's disease tremors are unresponsive to first line drugs and treatment with second line medications (clozapine, amantadine, clonazepam, propranolol, neurontin) should be attempted. In the small number of patients with disabling tremor that is refractory to all medications, neurosurgical intervention should be considered. Both thermocoagulation and deep brain stimulation at several different neuroanatomical sites (thalamus, globus pallidus, subthalamic nucleus) offer good to excellent tremor control with relatively low risk to the patient.
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Affiliation(s)
- J Marjama-Lyons
- Department of Neurology, University of Florida, Jacksonville, USA.
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Abstract
Radiosurgery will celebrate its Golden Jubilee in the year 2001. More than 100,000 patients throughout the world have undergone radiosurgery since Lars Leksell first described the technique in 1951. Rapid developments in neuroimaging and even robotic technology in the past decade have contributed to improved outcomes and wider applications for radiosurgery. A variety of different radiosurgical techniques have been developed in the past two decades. Numerous studies have examined the benefits and risks of radiosurgery performed with various devices. The long-term results of radiosurgery are now available, and these results have established radiosurgery as an effective noninvasive treatment method for intracranial vascular malformations and many tumors. Additional applications of radiosurgery for the treatment of malignant tumors and functional disorders are being assessed. Radiosurgery is an impressive combination of minimally invasive technologies administered by a multidisciplinary team of surgeons, oncologists, medical physicists, and engineers.
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Kamiryo T, Laws ER. An accurate adjustable applicator for magnetic resonance imaging-based stereotactic procedure using the Leksell G frame. Neurosurgery 1999; 45:397-9; discussion 399-400. [PMID: 10449088 DOI: 10.1097/00006123-199908000-00043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE An applicator system for the Leksell G frame was constructed to enable accurate placement of the frame for stereotactic magnetic resonance imaging (MRI) and successful stereotactic surgery. The applicator prevents inaccurate placement of the fiducial box on the patient's head and prevents contact of the frame holder with the patient's shoulder while in the MRI unit. It also helps to ensure optimal positioning of desired targets within the three-dimensional stereotactic space defined by the frame. METHODS The applicator is made of transparent acrylic plates, which simulate the fiducial box that is attached to the frame for the preoperative stereotactic MRI study. An air cuff at the top supports the frame at any desired height and makes minute adjustments possible. Side cuffs help to keep the frame at the desired position from right to left. Indicators attached to the frame for the anterior fiducial plate prevent potential contact of the plate with the anterior posts and help avoid a poor fit caused by bending of the frame from excessive torque on the cranium fixation screws. Indicators for the MRI frame holder on the foot screws predict potential collision of the holder with the patient's shoulder before actually applying the holder on the frame. The applicator shows the range and limits of the Leksell stereotactic arc. RESULTS This applicator system has been used effectively in more than 89 MRI-based functional stereotactic procedures. These include pallidotomy, thalamotomy, implantation of deep brain stimulators, and implantation of depth electrodes. It has functioned well and has facilitated excellent operative results in these cases. CONCLUSION This simple frame applicator eliminates the need for reapplication of the stereotactic frame and additional imaging studies, thus providing successful and appropriate frame placement for stereotactic surgery.
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Affiliation(s)
- T Kamiryo
- Department of Neurological Surgery, Virginia Neurological Institute, University of Virginia, Charlottesville, USA
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