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Babeliowsky WA, Bot M, Potters WV, van den Munckhof P, Blok ER, de Bie RM, Schuurman R, van Rootselaar A. Deep Brain Stimulation for Orthostatic Tremor: An Observational Study. Mov Disord Clin Pract 2024; 11:676-685. [PMID: 38586984 PMCID: PMC11145120 DOI: 10.1002/mdc3.14035] [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: 05/01/2023] [Revised: 02/09/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Primary orthostatic tremor (OT) can affect patients' life. Treatment of OT with deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (Vim) is described in a limited number of patients. The Vim and posterior subthalamic area (PSA) can be targeted in a single trajectory, allowing both stimulation of the Vim and/or dentatorubrothalamic tract (DRT). In essential tremor this is currently often used with positive effects. OBJECTIVE To evaluate the efficacy of Vim/DRT-DBS in OT-patients, based on standing time and Quality of Life (QoL), also on the long-term. Furthermore, to relate stimulation of the Vim and DRT, medial lemniscus (ML) and pyramidal tract (PT) to beneficial clinical and side-effects. METHODS Nine severely affected OT-patients received bilateral Vim/DRT-DBS. Primary outcome measure was standing time; secondary measures included self-reported measures, neurophysiological measures, structural analyses, surgical complications, stimulation-induced side-effects, and QoL up to 56 months. Stimulation of volume of tissue activated (VTA) were related to outcome measures. RESULTS Average maximum standing time increased from 41.0 s ± 51.0 s to 109.3 s ± 65.0 s after 18 months, with improvements measured in seven of nine patients. VTA (n = 7) overlapped with the DRT in six patients and with the ML and/or PT in six patients. All patients experienced side-effects and QoL worsened during the first year after surgery, which improved again during long-term follow-up, although remaining below age-related normal values. Most patients reported a positive effect of DBS. CONCLUSION Vim/DRT-DBS improved standing time in patients with severe OT. Observed side-effects are possibly related to stimulation of the ML and PT.
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Affiliation(s)
- Wietske A. Babeliowsky
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Maarten Bot
- NeurosurgeryAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Wouter V. Potters
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | | | - Edwin R. Blok
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Rob M.A. de Bie
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
- Amsterdam NeuroscienceNeurodegenerationAmsterdamThe Netherlands
| | - Rick Schuurman
- NeurosurgeryAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Anne‐Fleur van Rootselaar
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
- Amsterdam NeuroscienceNeurodegenerationAmsterdamThe Netherlands
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Ghimire S, Thapa B, Neupane D, Pokharel P. Outcomes of stereotactic thalamotomy in patients of essential tremor: A systematic review. J Clin Neurosci 2024; 126:38-45. [PMID: 38824802 DOI: 10.1016/j.jocn.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 05/18/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Essential tremor is a neurological condition associated with movement disorder with more prevalence among adult group of population. The burden of essential tremor is peaking globally but with the advancement in the area of functional neurosurgery such as stereotactic thalamotomy, the quality of life of such patients can be improved drastically. METHODS This systemic review was conducted in accordance to the guidance of preferred Reporting items for Systematic Review and Meta-Analysis(PRISMA). Databases of "PubMed", "Embase", "Web of Science", "Cinhal Plus", and "Scopus" from inception till 2023 was undertaken. A combination of keywords, Medical Subject Headings (MeSH), and search terms such as Search strategy for PubMed search was as follows: "stereotactic thalamotomy" AND "essential tremor". RESULTS This systematic review analyzed 9 studies with a total of 274 patients of essential tremor patients. Unilateral thalamotomy was carried out among 268 patients and bilateral thalamotomy in rest of the patients. Vim and Vom nucleus were the site of thalamotmy with ventral intermedius nucleus being the major one. Ten different types of clinical tremor rating scales were used to assess pre operative and post operative improvement in the tremor scales of the individual patients. Dysarthria and limb weakness was noted post operative complication in majority of the cases. CONCLUSION Our study revealed that stereotactic thalamotomy provided good functional outcome in patients of essential tremor who underwent unilateral thalamotomy compared to bilateral thalamotomy. The positive outcome outweighs the complications in such functional surgery.
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Affiliation(s)
- Sagun Ghimire
- Department of Neurosurgery, B and B Hospital, Gwarko, Lalitpur, Nepal.
| | - Bibechan Thapa
- Department of Surgery, West Hertfordshire Teaching Hospital, United Kingdom
| | - Durga Neupane
- B.P. Koirala Institute of Health Science, Dharan, Nepal
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Fenoy AJ, Chu ZD, Ritter RJ, Conner CR, Kralik SF. Evaluating functional connectivity differences between DBS ON/OFF states in essential tremor. Neurotherapeutics 2024:e00375. [PMID: 38824101 DOI: 10.1016/j.neurot.2024.e00375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 05/05/2024] [Accepted: 05/13/2024] [Indexed: 06/03/2024] Open
Abstract
Deep brain stimulation (DBS) targeting the ventral intermediate (Vim) nucleus of the thalamus is an effective treatment for essential tremor (ET). We studied 15 ET patients undergoing DBS to a major input/output tract of the Vim, the dentato-rubro-thalamic tract (DRTt), using resting state functional MRI (rsfMRI) to evaluate connectivity differences between DBS ON and OFF and elucidate significant regions most influential in impacting tremor control and/or concomitant gait ataxia. Anatomical/functional 1.5T MRIs were acquired and replicated for each DBS state. Tremor severity and gait ataxia severity were scored with DBS ON at optimal stimulation parameters and immediately upon DBS OFF. Whole brain analysis was performed using dual regression analysis followed by randomized permutation testing for multiple correction comparison. Regions of interest (ROI) analysis was also performed. All 15 patients had tremor improvement between DBS ON/OFF (p < 0.001). Whole brain analysis revealed significant connectivity changes between states in the left pre-central gyrus and left supplemental motor area. Group analysis of ROIs revealed that, with threshold p < 0.05, in DBS ON vs. OFF both tremor duration and tremor improvement were significantly correlated to changes in connectivity. A sub-group analysis of patients with greater ataxia had significantly decreased functional connectivity between multiple ROIs in the cortex and cerebellum when DBS was ON compared to OFF. Stimulation of the DRTt and concordant improvement of tremor resulted in connectivity changes seen in multiple regions outside the motor network; when combined with both structural and electrophysiologic connectivity, this may help to serve as a biomarker to improve DBS targeting and possibly predict outcome.
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Affiliation(s)
- Albert J Fenoy
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA; Departments of Neurosurgery and Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Zili D Chu
- Edward B. Singleton Department of Radiology, Baylor College of Medicine at Texas Children's Hospital, Houston, TX, USA
| | - Robert J Ritter
- Department of Neurosurgery, McGovern School of Medicine, UTHealth Houston, Houston, TX, USA
| | - Christopher R Conner
- Division of Neurosurgery, Dept. of Surgery, University of Connecticut, Hartford, CT, USA
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Baylor College of Medicine at Texas Children's Hospital, Houston, TX, USA
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Tabari F, Berger JI, Flouty O, Copeland B, Greenlee JD, Johari K. Speech, voice, and language outcomes following deep brain stimulation: A systematic review. PLoS One 2024; 19:e0302739. [PMID: 38728329 PMCID: PMC11086900 DOI: 10.1371/journal.pone.0302739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) reliably ameliorates cardinal motor symptoms in Parkinson's disease (PD) and essential tremor (ET). However, the effects of DBS on speech, voice and language have been inconsistent and have not been examined comprehensively in a single study. OBJECTIVE We conducted a systematic analysis of literature by reviewing studies that examined the effects of DBS on speech, voice and language in PD and ET. METHODS A total of 675 publications were retrieved from PubMed, Embase, CINHAL, Web of Science, Cochrane Library and Scopus databases. Based on our selection criteria, 90 papers were included in our analysis. The selected publications were categorized into four subcategories: Fluency, Word production, Articulation and phonology and Voice quality. RESULTS The results suggested a long-term decline in verbal fluency, with more studies reporting deficits in phonemic fluency than semantic fluency following DBS. Additionally, high frequency stimulation, left-sided and bilateral DBS were associated with worse verbal fluency outcomes. Naming improved in the short-term following DBS-ON compared to DBS-OFF, with no long-term differences between the two conditions. Bilateral and low-frequency DBS demonstrated a relative improvement for phonation and articulation. Nonetheless, long-term DBS exacerbated phonation and articulation deficits. The effect of DBS on voice was highly variable, with both improvements and deterioration in different measures of voice. CONCLUSION This was the first study that aimed to combine the outcome of speech, voice, and language following DBS in a single systematic review. The findings revealed a heterogeneous pattern of results for speech, voice, and language across DBS studies, and provided directions for future studies.
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Affiliation(s)
- Fatemeh Tabari
- Human Neurophysiology and Neuromodulation Laboratory, Department of Communication Sciences and Disorders, Louisiana State University, Baton Rouge, LA, United States of America
| | - Joel I. Berger
- Human Brain Research Laboratory, Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
| | - Oliver Flouty
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States of America
| | - Brian Copeland
- Department of Neurology, LSU Health Sciences Center, New Orleans, LA, United States of America
| | - Jeremy D. Greenlee
- Human Brain Research Laboratory, Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
- Iowa Neuroscience Institute, Iowa City, IA, United States of America
| | - Karim Johari
- Human Neurophysiology and Neuromodulation Laboratory, Department of Communication Sciences and Disorders, Louisiana State University, Baton Rouge, LA, United States of America
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Tian Y, Saradhi S, Bello E, Johnson MD, D’Eleuterio G, Popovic MR, Lankarany M. Model-based closed-loop control of thalamic deep brain stimulation. FRONTIERS IN NETWORK PHYSIOLOGY 2024; 4:1356653. [PMID: 38650608 PMCID: PMC11033853 DOI: 10.3389/fnetp.2024.1356653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
Introduction: Closed-loop control of deep brain stimulation (DBS) is beneficial for effective and automatic treatment of various neurological disorders like Parkinson's disease (PD) and essential tremor (ET). Manual (open-loop) DBS programming solely based on clinical observations relies on neurologists' expertise and patients' experience. Continuous stimulation in open-loop DBS may decrease battery life and cause side effects. On the contrary, a closed-loop DBS system uses a feedback biomarker/signal to track worsening (or improving) of patients' symptoms and offers several advantages compared to the open-loop DBS system. Existing closed-loop DBS control systems do not incorporate physiological mechanisms underlying DBS or symptoms, e.g., how DBS modulates dynamics of synaptic plasticity. Methods: In this work, we propose a computational framework for development of a model-based DBS controller where a neural model can describe the relationship between DBS and neural activity and a polynomial-based approximation can estimate the relationship between neural and behavioral activities. A controller is used in our model in a quasi-real-time manner to find DBS patterns that significantly reduce the worsening of symptoms. By using the proposed computational framework, these DBS patterns can be tested clinically by predicting the effect of DBS before delivering it to the patient. We applied this framework to the problem of finding optimal DBS frequencies for essential tremor given electromyography (EMG) recordings solely. Building on our recent network model of ventral intermediate nuclei (Vim), the main surgical target of the tremor, in response to DBS, we developed neural model simulation in which physiological mechanisms underlying Vim-DBS are linked to symptomatic changes in EMG signals. By using a proportional-integral-derivative (PID) controller, we showed that a closed-loop system can track EMG signals and adjust the stimulation frequency of Vim-DBS so that the power of EMG reaches a desired control target. Results and discussion: We demonstrated that the model-based DBS frequency aligns well with that used in clinical studies. Our model-based closed-loop system is adaptable to different control targets and can potentially be used for different diseases and personalized systems.
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Affiliation(s)
- Yupeng Tian
- Krembil Brain Institute—University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
| | - Srikar Saradhi
- Krembil Brain Institute—University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Edward Bello
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Matthew D. Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States
| | | | - Milos R. Popovic
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Milad Lankarany
- Krembil Brain Institute—University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application, University Health Network and University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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Martinez-Nunez AE, Sarmento FP, Chandra V, Hess CW, Hilliard JD, Okun MS, Wong JK. Management of essential tremor deep brain stimulation-induced side effects. Front Hum Neurosci 2024; 18:1353150. [PMID: 38454907 PMCID: PMC10918853 DOI: 10.3389/fnhum.2024.1353150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/01/2024] [Indexed: 03/09/2024] Open
Abstract
Deep brain stimulation (DBS) is an effective surgical therapy for carefully selected patients with medication refractory essential tremor (ET). The most popular anatomical targets for ET DBS are the ventral intermedius nucleus (VIM) of the thalamus, the caudal zona incerta (cZI) and the posterior subthalamic area (PSA). Despite extensive knowledge in DBS programming for tremor suppression, it is not uncommon to experience stimulation induced side effects related to DBS therapy. Dysarthria, dysphagia, ataxia, and gait impairment are common stimulation induced side effects from modulation of brain tissue that surround the target of interest. In this review, we explore current evidence about the etiology of stimulation induced side effects in ET DBS and provide several evidence-based strategies to troubleshoot, reprogram and retain tremor suppression.
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Affiliation(s)
- Alfonso Enrique Martinez-Nunez
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Filipe P. Sarmento
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
| | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Christopher William Hess
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Justin David Hilliard
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
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Shepherd H, Heartshorne R, Osman-Farah J, Macerollo A. Dual target deep brain stimulation for complex essential and dystonic tremor - A 5-year follow up. J Neurol Sci 2024; 457:122887. [PMID: 38295533 DOI: 10.1016/j.jns.2024.122887] [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: 07/17/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Essential tremor (ET) is characterized by action tremor of the upper limbs, head tremor and voice tremor. Dystonic tremor (DT) is produced by muscle contractions in a body affected by dystonia. Deep brain stimulation (DBS) of ventral intermediate nucleus of the thalamus (VIM) is the most well-known advanced treatment for medication-refractory tremor. However, decline in efficacy overtime has led to explore other targets. This study aimed to measure the efficacy of bilateral dual targeting ViM/caudal Zona Incerta (cZI) stimulation on tremor control. A secondary aim was to evaluate if there was a difference in the efficacy between ET and DT. METHODS 36 patients were retrospectively recruited at the Walton NHS Foundation Trust, Liverpool, UK. Patients were assessed pre-operatively, and then at 1-year, 3-years, and 5-years post-operatively with the following scales: Fahn-Tolosa-Marin tremor rating (FTMTR) scale, EuroQol-5D, and Hospital Anxiety and Depression Scale. RESULTS Bilateral ViM-cZI DBS significantly improved overall tremor score by 45.1% from baseline to 3-years post-operatively (p < 0.001). It continued to show improvement in overall FTMTR score by 30.7% at 5-years but this failed to meet significance. However, there was no significant improvement of mood or quality of life (QoL) scores. ET group on average showed a significant better clinical outcome compared to the DT group (p > 0.001). CONCLUSIONS Our study found that bilateral ViM-cZI DBS treatment had a favourable effect on motor symptoms sustained over the 5-years in tremor patients, especially in ET group. There was limited effect on mood and QoL with similar trends in outcomes for both tremor types.
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Affiliation(s)
- Hilary Shepherd
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK; University of Liverpool Medical School, Liverpool, UK.
| | - Rosie Heartshorne
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK
| | - Jibril Osman-Farah
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK
| | - Antonella Macerollo
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK
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Wirth T, Ferreira F, Vijiaratnam N, Girges C, Pakzad A, de Roquemaurel A, Sinani O, Hyam J, Hariz M, Zrinzo L, Akram H, Limousin P, Foltynie T. Parkinson's Disease Tremor Differentially Responds to Levodopa and Subthalamic Stimulation. Mov Disord Clin Pract 2023; 10:1639-1649. [PMID: 37982119 PMCID: PMC10654834 DOI: 10.1002/mdc3.13876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 11/21/2023] Open
Abstract
Background Tremor in Parkinson's disease (PD) has an inconsistent response to levodopa and subthalamic deep brain stimulation (STN-DBS). Objectives To identify predictive factors of PD tremor responsiveness to levodopa and STN-DBS. Material and Methods PD patients with upper limb tremor who underwent STN-DBS were included. The levodopa responsiveness of tremor (overall, postural, and rest sub-components), was assessed using the relevant Unified Parkinson's Disease Rating Scale-III items performed during the preoperative assessment. Post-surgical outcomes were similarly assessed ON and OFF stimulation. A score for the rest/postural tremor ratio was used to determine the influence of rest and postural tremor severity on STN-DBS outcome. Factors predictive of tremor responsiveness were determined using multiple linear regression modeling. Volume of tissue activated measurement coupled to voxel-based analysis was performed to identify anatomical clusters associated with motor symptoms improvement. Results One hundred and sixty five patients were included in this study. Male gender was negatively correlated with tremor responsiveness to levodopa, whereas the ratio of rest/postural tremor was positively correlated with both levodopa responsiveness and STN-DBS tremor outcome. Clusters corresponding to improvement of tremor were in the subthalamic nucleus, the zona incerta and the thalamus, whereas clusters corresponding to improvement for akinesia and rigidity were located within the subthalamic nucleus. Conclusion More severe postural tremor and less severe rest tremor were associated with both poorer levodopa and STN-DBS response. The different locations of clusters associated with best correction of tremor and other parkinsonian features suggest that STN-DBS effect on PD symptoms is underpinned by the modulation of different networks.
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Affiliation(s)
- Thomas Wirth
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
- Neurology DepartmentStrasbourg University HospitalStrasbourgFrance
- Institute of Genetics and Cellular and Molecular BiologyINSERM‐U964, CNRS‐UMR7104, University of StrasbourgStrasbourgFrance
- Strasbourg Translational Medicine FederationUniversity of StrasbourgStrasbourgFrance
| | - Francisca Ferreira
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
- Wellcome Centre for Human NeuroimagingLondonUnited Kingdom
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Christine Girges
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Ashkan Pakzad
- EPSRC Centre for Doctoral Training i4healthUniversity College LondonLondonUnited Kingdom
| | - Alexis de Roquemaurel
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Olga Sinani
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Jonathan Hyam
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Marwan Hariz
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
- Department of Clinical Science, NeuroscienceUmeå UniversityUmeåSweden
| | - Ludvic Zrinzo
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Harith Akram
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Patricia Limousin
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Thomas Foltynie
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology and the National Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
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Stenmark Persson R, Fytagoridis A, Ryzhkov M, Hariz M, Blomstedt P. Long-Term Follow-Up of Unilateral Deep Brain Stimulation Targeting the Caudal Zona Incerta in 13 Patients with Parkinsonian Tremor. Stereotact Funct Neurosurg 2023; 101:369-379. [PMID: 37879313 DOI: 10.1159/000533793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/22/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD) and other movement disorders. The ventral intermediate nucleus of the thalamus is considered as the target of choice for tremor disorders, including tremor-dominant PD not suitable for DBS in the subthalamic nucleus (STN). In the last decade, several studies have shown promising results on tremor from DBS in the posterior subthalamic area (PSA), including the caudal zona incerta (cZi) located posteromedial to the STN. The aim of this study was to evaluate the long-term effect of unilateral cZi/PSA-DBS in patients with tremor-dominant PD. METHODS Thirteen patients with PD with medically refractory tremor were included. The patients were evaluated using the motor part of the Unified Parkinson Disease Rating Scale (UPDRS) off/on medication before surgery and off/on medication and stimulation 1-2 years (short-term) after surgery and at a minimum of 3 years after surgery (long-term). RESULTS At short-term follow-up, DBS improved contralateral tremor by 88% in the off-medication state. This improvement persisted after a mean of 62 months. Contralateral bradykinesia was improved by 40% at short-term and 20% at long-term follow-up, and the total UPDRS-III by 33% at short-term and by 22% at long-term follow-up with stimulation alone. CONCLUSIONS Unilateral cZi/PSA-DBS seems to remain an effective treatment for patients with severe Parkinsonian tremor several years after surgery. There was also a modest improvement on bradykinesia.
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Affiliation(s)
| | - Anders Fytagoridis
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institute, Stockholm, Sweden
| | - Maxim Ryzhkov
- Cranial and Spinal Technologies, Medtronic, Lafayette, Colorado, USA
| | - Marwan Hariz
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
- UCL Queen Square Institute of Neurology, London, UK
| | - Patric Blomstedt
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
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Ferreira Felloni Borges Y, Cheyuo C, Lozano AM, Fasano A. Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound. Expert Rev Neurother 2023; 23:603-619. [PMID: 37288812 DOI: 10.1080/14737175.2023.2221789] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered. AREAS COVERED In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion. EXPERT OPINION DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.
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Affiliation(s)
- Yuri Ferreira Felloni Borges
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
- Department of Parkinson's Disease & Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital, Gravedona Ed Uniti, Como, Italy
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11
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Holcomb JM, Chopra R, Feltrin FS, Elkurd M, El-Nazer R, McKenzie L, O’Suilleabhain P, Maldjian JA, Dauer W, Shah BR. Improving tremor response to focused ultrasound thalamotomy. Brain Commun 2023; 5:fcad165. [PMID: 37533544 PMCID: PMC10390385 DOI: 10.1093/braincomms/fcad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 08/04/2023] Open
Abstract
MRI-guided high-intensity focused ultrasound thalamotomy is an incisionless therapy for essential tremor. To reduce adverse effects, the field has migrated to treating at 2 mm above the anterior commissure-posterior commissure plane. We perform MRI-guided high-intensity focused ultrasound with an advanced imaging targeting technique, four-tract tractography. Four-tract tractography uses diffusion tensor imaging to identify the critical white matter targets for tremor control, the decussating and non-decussating dentatorubrothalamic tracts, while the corticospinal tract and medial lemniscus are identified to be avoided. In some patients, four-tract tractography identified a risk of damaging the medial lemniscus or corticospinal tract if treated at 2 mm superior to the anterior commissure-posterior commissure plane. In these patients, we chose to target 1.2-1.5 mm superior to the anterior commissure-posterior commissure plane. In these patients, post-operative imaging revealed that the focused ultrasound lesion extended into the posterior subthalamic area. This study sought to determine if patients with focused ultrasound lesions that extend into the posterior subthalamic area have a differnce in tremor improvement than those without. Twenty essential tremor patients underwent MRI-guided high-intensity focused ultrasound and were retrospectively classified into two groups. Group 1 included patients with an extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. Group 2 included patients without extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. For each patient, the percent change in postural tremor, kinetic tremor and Archimedes spiral scores were calculated between baseline and a 3-month follow-up. Two-tailed Wilcoxon rank-sum tests were used to compare the improvement in tremor scores, the total number of sonications, thermal dose to achieve initial tremor response, and skull density ratio between groups. Group 1 had significantly greater postural, kinetic, and Archimedes spiral score percent improvement than Group 2 (P values: 5.41 × 10-5, 4.87 × 10-4, and 5.41 × 10-5, respectively). Group 1 also required significantly fewer total sonications to control the tremor and a significantly lower thermal dose to achieve tremor response (P values: 6.60 × 10-4 and 1.08 × 10-5, respectively). No significant group differences in skull density ratio were observed (P = 1.0). We do not advocate directly targeting the posterior subthalamic area with MRI-guided high-intensity focused ultrasound because the shape of the focused ultrasound lesion can result in a high risk of adverse effects. However, when focused ultrasound lesions naturally extend from the thalamus into the posterior subthalamic area, they provide greater tremor control than those that only involve the thalamus.
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Affiliation(s)
- James M Holcomb
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rajiv Chopra
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Fabricio S Feltrin
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Mazen Elkurd
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rasheda El-Nazer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Lauren McKenzie
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | | | - Joseph A Maldjian
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - William Dauer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
- O’Donnell Brain Institute, UTSW Medical Center, Dallas, TX 75235, USA
| | - Bhavya R Shah
- Correspondence to: Bhavya R. Shah Department of Radiology, UTSW Medical Center, 1801 Inwood Rd Dallas, TX 75235, USA E-mail:
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12
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Boogers A, Peeters J, Van Bogaert T, Rusz J, Bogaert-Miclaus C, Loret G, De Vloo P, Vandenberghe W, Nuttin B, Mc Laughlin M. Acute stimulation with symmetric biphasic pulses induces less ataxia compared to cathodic pulses in DBS for essential tremor. Parkinsonism Relat Disord 2023; 111:105435. [PMID: 37187082 DOI: 10.1016/j.parkreldis.2023.105435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Symmetric biphasic pulses have been shown to acutely increase the therapeutic window of ventralis intermedius deep brain stimulation (Vim-DBS) for essential tremor (ET) compared to cathodic pulses. Acute supratherapeutic stimulation can induce ataxic side effects in Vim-DBS. OBJECTIVE To investigate the effect on tremor, ataxia and dysarthria of 3 h of biphasic stimulation in patients with DBS for ET. METHODS A randomized, doubled-blind, cross-over design was used to compare standard cathodic pulses with symmetric biphasic pulses (anode-first) during a 3-h period per pulse shape. During each 3-h period, all stimulation parameters were identical, except for the pulse shape. Tremor (Fahn-Tolosa-Marin Tremor Rating Scale), ataxia (International Cooperative Ataxia Rating Scale) and speech (acoustic and perceptual measures) were assessed hourly during the 3-h periods. RESULTS Twelve ET patients were included. During the 3-h stimulation period, tremor control was equivalent between the two pulse shapes. Biphasic pulses elicited significantly less ataxia than cathodic pulses (p = 0.006). Diadochokinesis rate of speech was better for the biphasic pulse (p = 0.048), but other measures for dysarthria were not significantly different between the pulses. CONCLUSION Symmetric biphasic pulses induce less ataxia than conventional pulses after 3 h of stimulation DBS in ET patients.
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Affiliation(s)
- Alexandra Boogers
- Exp ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium; Department of Neurology, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jana Peeters
- Exp ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Tine Van Bogaert
- Exp ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jan Rusz
- Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University in Prague, Technicka 2, 160 00, Prague 6, Czech Republic
| | | | - Griet Loret
- Department of Neurology, AZ Sint-Lucas, Groenebriel 1, 9000, Gent, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium; Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Parkinson Research, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium; Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Myles Mc Laughlin
- Exp ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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13
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Cosgrove GR, Lipsman N, Lozano AM, Chang JW, Halpern C, Ghanouni P, Eisenberg H, Fishman P, Taira T, Schwartz ML, McDannold N, Hayes M, Ro S, Shah B, Gwinn R, Santini VE, Hynynen K, Elias WJ. Magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: 5-year follow-up results. J Neurosurg 2023; 138:1028-1033. [PMID: 35932269 PMCID: PMC10193464 DOI: 10.3171/2022.6.jns212483] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 06/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate, at 4 and 5 years posttreatment, the long-term safety and efficacy of unilateral MRI-guided focused ultrasound (MRgFUS) thalamotomy for medication-refractory essential tremor in a cohort of patients from a prospective, controlled, multicenter clinical trial. METHODS Outcomes per the Clinical Rating Scale for Tremor (CRST), including postural tremor scores (CRST Part A), combined hand tremor/motor scores (CRST Parts A and B), and functional disability scores (CRST Part C), were measured by a qualified neurologist. The Quality of Life in Essential Tremor Questionnaire (QUEST) was used to assess quality of life. CRST and QUEST scores at 48 and 60 months post-MRgFUS were compared to those at baseline to assess treatment efficacy and durability. All adverse events (AEs) were reported. RESULTS Forty-five and 40 patients completed the 4- and 5-year follow-ups, respectively. CRST scores for postural tremor (Part A) for the treated hand remained significantly improved by 73.3% and 73.1% from baseline at both 48 and 60 months posttreatment, respectively (both p < 0.0001). Combined hand tremor/motor scores (Parts A and B) also improved by 49.5% and 40.4% (p < 0.0001) at each respective time point. Functional disability scores (Part C) increased slightly over time but remained significantly improved through the 5 years (p < 0.0001). Similarly, QUEST scores remained significantly improved from baseline at year 4 (p < 0.0001) and year 5 (p < 0.0003). All previously reported AEs remained mild or moderate, and no new AEs were reported. CONCLUSIONS Unilateral MRgFUS thalamotomy demonstrates sustained and significant tremor improvement at 5 years with an overall improvement in quality-of-life measures and without any progressive or delayed complications. Clinical trial registration no.: NCT01827904 (ClinicalTrials.gov).
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Affiliation(s)
| | | | - Andres M. Lozano
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | | | - Pejman Ghanouni
- Radiology, Stanford University School of Medicine, Stanford, California
| | | | - Paul Fishman
- Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | | | - Nathan McDannold
- Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Susie Ro
- Neurology, Swedish Neuroscience Center, Seattle, Washington; and
| | - Binit Shah
- Neurology, University of Virginia School of Medicine, Charlottesville, Virginia
| | | | | | - Kullervo Hynynen
- Radiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
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14
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Lateral cerebellothalamic tract activation underlies DBS therapy for Essential Tremor. Brain Stimul 2023; 16:445-455. [PMID: 36746367 DOI: 10.1016/j.brs.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND While deep brain stimulation (DBS) therapy can be effective at suppressing tremor in individuals with medication-refractory Essential Tremor, patient outcome variability remains a significant challenge across centers. Proximity of active electrodes to the cerebellothalamic tract (CTT) is likely important in suppressing tremor, but how tremor control and side effects relate to targeting parcellations within the CTT and other pathways in and around the ventral intermediate (VIM) nucleus of thalamus remain unclear. METHODS Using ultra-high field (7T) MRI, we developed high-dimensional, subject-specific pathway activation models for 23 directional DBS leads. Modeled pathway activations were compared with post-hoc analysis of clinician-optimized DBS settings, paresthesia thresholds, and dysarthria thresholds. Mixed-effect models were utilized to determine how the six parcellated regions of the CTT and how six other pathways in and around the VIM contributed to tremor suppression and induction of side effects. RESULTS The lateral portion of the CTT had the highest activation at clinical settings (p < 0.05) and a significant effect on tremor suppression (p < 0.001). Activation of the medial lemniscus and posterior-medial CTT was significantly associated with severity of paresthesias (p < 0.001). Activation of the anterior-medial CTT had a significant association with dysarthria (p < 0.05). CONCLUSIONS This study provides a detailed understanding of the fiber pathways responsible for therapy and side effects of DBS for Essential Tremor, and suggests a model-based programming approach will enable more selective activation of lateral fibers within the CTT.
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15
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Matthews LG, Puryear CB, Correia SS, Srinivasan S, Belfort GM, Pan MK, Kuo SH. T-type calcium channels as therapeutic targets in essential tremor and Parkinson's disease. Ann Clin Transl Neurol 2023; 10:462-483. [PMID: 36738196 PMCID: PMC10109288 DOI: 10.1002/acn3.51735] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023] Open
Abstract
Neuronal action potential firing patterns are key components of healthy brain function. Importantly, restoring dysregulated neuronal firing patterns has the potential to be a promising strategy in the development of novel therapeutics for disorders of the central nervous system. Here, we review the pathophysiology of essential tremor and Parkinson's disease, the two most common movement disorders, with a focus on mechanisms underlying the genesis of abnormal firing patterns in the implicated neural circuits. Aberrant burst firing of neurons in the cerebello-thalamo-cortical and basal ganglia-thalamo-cortical circuits contribute to the clinical symptoms of essential tremor and Parkinson's disease, respectively, and T-type calcium channels play a key role in regulating this activity in both the disorders. Accordingly, modulating T-type calcium channel activity has received attention as a potentially promising therapeutic approach to normalize abnormal burst firing in these diseases. In this review, we explore the evidence supporting the theory that T-type calcium channel blockers can ameliorate the pathophysiologic mechanisms underlying essential tremor and Parkinson's disease, furthering the case for clinical investigation of these compounds. We conclude with key considerations for future investigational efforts, providing a critical framework for the development of much needed agents capable of targeting the dysfunctional circuitry underlying movement disorders such as essential tremor, Parkinson's disease, and beyond.
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Affiliation(s)
| | - Corey B Puryear
- Praxis Precision Medicines, Boston, Massachusetts, 02110, USA
| | | | - Sharan Srinivasan
- Praxis Precision Medicines, Boston, Massachusetts, 02110, USA.,Department of Neurology, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | | | - Ming-Kai Pan
- Department and Graduate Institute of Pharmacology, National Taiwan University College of Medicine, Taipei, 10051, Taiwan.,Neurobiology and Cognitive Science Center, National Taiwan University, Taipei, 10617, Taiwan.,Department of Medical Research, National Taiwan University Hospital, Taipei, 10002, Taiwan.,Cerebellar Research Center, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, 64041, Taiwan
| | - Sheng-Han Kuo
- Department of Neurology, Columbia University, New York, New York, 10032, USA.,Initiative for Columbia Ataxia and Tremor, Columbia University, New York, New York, 10032, USA
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16
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Goc B, Roch-Zniszczoł A, Larysz D, Zarudzki Ł, Stąpór-Fudzińska M, Rożek A, Woźniak G, Boczarska-Jedynak M, Miszczyk L, Napieralska A. The Effectiveness and Toxicity of Frameless CyberKnife Based Radiosurgery for Parkinson's Disease-Phase II Study. Biomedicines 2023; 11:biomedicines11020288. [PMID: 36830825 PMCID: PMC9952894 DOI: 10.3390/biomedicines11020288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Frame-based stereotactic radiosurgery (SRS) has an established role in the treatment of tremor in patients with Parkinson's disease (PD). The low numbers of studies of frameless approaches led to our prospective phase 2 open-label single-arm clinical trial (NCT02406105), which aimed to evaluate the safety and efficacy of CyberKnife frameless SRS. Twenty-three PD patients were irradiated on the area of the thalamic ventral nuclei complex with gradually increasing doses of 70 to 105 Gy delivered in a single fraction. After SRS, patients were monitored for tremor severity and the toxicity of the treatment. Both subjective improvement and dose-dependent efficacy were analysed using standard statistical tests. The median follow-up was 23 months, and one patient died after COVID-19 infection. Another two patients were lost from follow-up. Hyper-response resulting in vascular toxicity and neurologic complications was observed in two patients irradiated with doses of 95 and 100 Gy, respectively. A reduction in tremor severity was observed in fifteen patients, and six experienced stagnation. A constant response during the whole follow-up was observed in 67% patients. A longer median response time was achieved in patients irradiated with doses equal to or less than 85 Gy. Only two patients declared no improvement after SRS. The efficacy of frameless SRS is high and could improve tremor control in a majority of patients. The complication rate is low, especially when doses below 90 Gy are applied. Frameless SRS could be offered as an alternative for patients ineligible for deep brain stimulation; however, studies regarding optimal dose are required.
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Affiliation(s)
- Bartłomiej Goc
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Agata Roch-Zniszczoł
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Dawid Larysz
- Department of Head and Neck Surgery for Children and Adolescents, University of Warmia and Mazury in Olsztyn, 10-561 Olsztyn, Poland
| | - Łukasz Zarudzki
- Department of Radiology and Diagnostic Imaging, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Małgorzata Stąpór-Fudzińska
- Department of Radiotherapy Planning, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Agnieszka Rożek
- “Kangur” Centre for Treatment of CNS Disorders and Child Development Support in Katowice, 40-594 Katowice, Poland
| | - Grzegorz Woźniak
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Magdalena Boczarska-Jedynak
- Neurology and Restorative Medicine Department, Health Institute dr Boczarska-Jedynak, 32-600 Oświęcim, Poland
| | - Leszek Miszczyk
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Aleksandra Napieralska
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
- Correspondence:
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17
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Ruckart KW, Wilson C, Moya-Mendez ME, Madden LL, Laxton A, Siddiqui MS. Effect of Ventral Intermediate Nucleus Deep Brain Stimulation on Vocal Tremor in Essential Tremor. Tremor Other Hyperkinet Mov (N Y) 2023; 13:13. [PMID: 37152623 PMCID: PMC10162197 DOI: 10.5334/tohm.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023] Open
Abstract
Background There is a paucity of literature examining the effect of Ventral Intermediate Nucleus (VIM) deep brain stimulation (DBS) on voice in patients with vocal tremor (VT). Objective Investigate the effect of unilateral and bilateral VIM DBS on voice in patients with Essential Tremor (ET) and VT. Methods All patients receiving VIM DBS surgery underwent voice evaluation pre- and six-months post-operatively. We collected patient-reported quality-of-life outcome measures and acoustic voice measures of sustained phonation and connected speech. Acoustic measures specific to VT included amplitude tremor intensity index (ATRI), frequency tremor intensity index (FTRI), rate and extent of F0 modulation, and rate and extent of intensity modulation. Results Five patients, age 72.8 ± 2.6 years, 4 female, 1 male with mean disease duration of 29 ± 26.2 years met the inclusion criteria and were included. Two subjects had bilateral procedure and three had unilateral. We observed significant improvements in measures of vocal tremor including ATRI, FTRI, rate of F0 modulation, rate of intensity modulation, and extent of intensity modulation, as well as patient reported voice-related quality of life measured by VHI-10. Bilateral VIM DBS cases showed greater improvement in VT than unilateral cases. Conclusion Both unilateral and bilateral VIM DBS resulted in significant improvement of VT, with more improvement demonstrated in patients having bilateral as compared to unilateral VIM DBS. In addition, patients also reported significant improvements in voice-related quality of life. If larger studies confirm our results, VIM DBS has the potential to become a treatment specifically for disabling VT.
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Affiliation(s)
- Kathryn W. Ruckart
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | - Caroline Wilson
- Department of Radiology, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | | | - Lyndsay L. Madden
- Department of Otolaryngology-Head and Neck Surgery, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | - Adrian Laxton
- Department of Neurology, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
| | - Mustafa S. Siddiqui
- Department of Neurology, Atrium Health Wake Forest Baptist/Wake Forest University School of Medicine, Winston-Salem, NC, US
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18
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Patterned Stimulation of the Chrimson Opsin in Glutamatergic Motor Thalamus Neurons Improves Forelimb Akinesia in Parkinsonian Rats. Neuroscience 2022; 507:64-78. [PMID: 36343721 DOI: 10.1016/j.neuroscience.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/20/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
Parkinson's disease (PD) is a motor disorder charactertised by altered neural activity throughout the basal ganglia-thalamocortical circuit. Electrical deep brain stimulation (DBS) is efficacious in alleviating motor symptoms, but has several notable side-effects, most likely reflecting the non-specific nature of electrical stimulation and/or the brain regions targeted. We determined whether specific optogenetic activation of glutamatergic motor thalamus (Mthal) neurons alleviated forelimb akinesia in a chronic rat model of PD. Parkinsonian rats (unilateral 6-hydroxydopamine injection) were injected with an adeno-associated viral vector (AAV5-CaMKII-Chrimson-GFP) to transduce glutamatergic Mthal neurons with the red-shifted Chrimson opsin. Optogenetic stimulation with orange light at 15 Hz tonic and a physiological pattern, previously recorded from a Mthal neuron in a control rat, significantly increased forelimb use in the reaching test (p < 0.01). Orange light theta burst stimulation, 15 Hz and control reaching patterns significantly reduced akinesia (p < 0.0001) assessed by the step test. In contrast, forelimb use in the cylinder test was unaffected by orange light stimulation with any pattern. Blue light (control) stimulation failed to alter behaviours. Activation of Chrimson using complex patterns in the Mthal may be an alternative treatment to recover movement in PD. These vector and opsin changes are important steps towards translating optogenetic stimulation to humans.
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Voice Tremor and Botulinum Neurotoxin Therapy: A Contemporary Review. Toxins (Basel) 2022; 14:toxins14110773. [PMID: 36356023 PMCID: PMC9698548 DOI: 10.3390/toxins14110773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Voice tremor is a common, yet debilitating symptom for patients suffering from a number of tremor-associated disorders. The key to targeting effective treatments for voice tremor requires a fundamental understanding of the pathophysiology that underpins the tremor mechanism and accurate identification of the disease in affected patients. An updated review of the literature detailing the current understanding of voice tremor (with or without essential tremor), its accurate diagnosis and targeted treatment options was conducted, with a specific focus on the role of botulinum neurotoxin. Judicious patient selection, following detailed characterisation of voice tremor qualities, is essential to optimising treatment outcomes for botulinum neurotoxin therapy, as well as other targeted therapies. Further focused investigation is required to characterise the response to targeted treatment in voice tremor patients and to guide the development of innovative treatment options.
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Abusrair AH, Elsekaily W, Bohlega S. Tremor in Parkinson's Disease: From Pathophysiology to Advanced Therapies. Tremor Other Hyperkinet Mov (N Y) 2022; 12:29. [PMID: 36211804 PMCID: PMC9504742 DOI: 10.5334/tohm.712] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
Background Tremor is one of the most prevalent symptoms in Parkinson's Disease (PD). The progression and management of tremor in PD can be challenging, as response to dopaminergic agents might be relatively poor, particularly in patients with tremor-dominant PD compared to the akinetic/rigid subtype. In this review, we aim to highlight recent advances in the underlying pathogenesis and treatment modalities for tremor in PD. Methods A structured literature search through Embase was conducted using the terms "Parkinson's Disease" AND "tremor" OR "etiology" OR "management" OR "drug resistance" OR "therapy" OR "rehabilitation" OR "surgery." After initial screening, eligible articles were selected with a focus on published literature in the last 10 years. Discussion The underlying pathophysiology of tremor in PD remains complex and incompletely understood. Neurodegeneration of dopaminergic neurons in the retrorubral area, in addition to high-power neural oscillations in the cerebello-thalamo-cortical circuit and the basal ganglia, play a major role. Levodopa is the first-line therapeutic option for all motor symptoms, including tremor. The addition of dopamine agonists or anticholinergics can lead to further tremor reduction. Botulinum toxin injection is an effective alternative for patients with pharmacological-resistant tremor who are not seeking advanced therapies. Deep brain stimulation is the most well-established advanced therapy owing to its long-term efficacy, reversibility, and effectiveness in other motor symptoms and fluctuations. Magnetic resonance-guided focused ultrasound is a promising modality, which has the advantage of being incisionless. Cortical and peripheral electrical stimulation are non-invasive innovatory techniques that have demonstrated good efficacy in suppressing intractable tremor.
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Affiliation(s)
- Ali H. Abusrair
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Neurology, Department of Internal Medicine, Qatif Health Network, Qatif, Saudi Arabia
| | - Walaa Elsekaily
- College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Saeed Bohlega
- Movement Disorders Program, Neurosciences Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Österlund E, Blomstedt P, Fytagoridis A. Ipsilateral Effects of Unilateral Deep Brain Stimulation for Essential Tremor. Stereotact Funct Neurosurg 2022; 100:248-252. [PMID: 35760039 DOI: 10.1159/000525325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 05/06/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Essential tremor (ET) is the most common adult movement disorder. For the relatively large group of patients who do not respond adequately to pharmacological therapy, deep brain stimulation (DBS) is a well-established treatment option. Most ET patients will have bilateral symptoms, and many of them receive bilateral DBS. Unilateral DBS is however still the most common procedure, and some papers suggest an ipsilateral effect in these patients. OBJECTIVES The aim of this study was to analyze if there is an ipsilateral effect of DBS for ET. METHOD We retrospectively analyzed our patient cohort with DBS surgery from 1996 to 2017, selecting patients with ET that underwent surgery with unilateral DBS without previous DBS or lesional surgery. A total number of 68 patients (39 males, 29 females) were identified. The patients were evaluated twice: first, at a mean time of 12 months after surgery defined as short-term follow-up and then again at a mean time of 49 months after surgery defined as long-term follow-up, using the clinical rating scale for tremor (CRST). RESULTS The total CRST score was reduced from mean 49.5 points at baseline before surgery to 20.2 (p < 0.001) at short-term and 28.3 (p < 0.001) at long-term follow-up. Contralateral tremor was reduced from mean 6.1 to 0.4 (p < 0.001) and 1.2 (p < 0.001), respectively. Contralateral hand function was reduced from 11.5 to 2.6 (p < 0.001) and 4.6 (p < 0.001), respectively. Ipsilateral hand function scored 9 at baseline, 8.3 at 1 year, and then again 9.4 at long-term follow-up. Ipsilateral tremor scored 4.0 at baseline, 3.7 at 1 year, and 4.3 at long-term follow-up. Neither ipsilateral hand function nor ipsilateral tremor showed significant difference. CONCLUSIONS There was no difference in severity of ipsilateral tremor, neither at 1 year nor in the long term. We believe ipsilateral effects of DBS for ET merits limited consideration regarding decision-making or patient counseling before surgery.
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Affiliation(s)
- Erik Österlund
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institutet, Solna, Sweden
| | - Patric Blomstedt
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Fytagoridis
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institutet, Solna, Sweden
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22
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Neuroimaging signatures predicting motor improvement to focused ultrasound subthalamotomy in Parkinson's disease. NPJ Parkinsons Dis 2022; 8:70. [PMID: 35665753 PMCID: PMC9166695 DOI: 10.1038/s41531-022-00332-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/13/2022] [Indexed: 11/24/2022] Open
Abstract
Subthalamotomy using transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) is a novel and promising treatment for Parkinson’s Disease (PD). In this study, we investigate if baseline brain imaging features can be early predictors of tcMRgFUS-subthalamotomy efficacy, as well as which are the post-treatment brain changes associated with the clinical outcomes. Towards this aim, functional and structural neuroimaging and extensive clinical data from thirty-five PD patients enrolled in a double-blind tcMRgFUS-subthalamotomy clinical trial were analyzed. A multivariate cross-correlation analysis revealed that the baseline multimodal imaging data significantly explain (P < 0.005, FWE-corrected) the inter-individual variability in response to treatment. Most predictive features at baseline included neural fluctuations in distributed cortical regions and structural integrity in the putamen and parietal regions. Additionally, a similar multivariate analysis showed that the population variance in clinical improvements is significantly explained (P < 0.001, FWE-corrected) by a distributed network of concurrent functional and structural brain changes in frontotemporal, parietal, occipital, and cerebellar regions, as opposed to local changes in very specific brain regions. Overall, our findings reveal specific quantitative brain signatures highly predictive of tcMRgFUS-subthalamotomy responsiveness in PD. The unanticipated weight of a cortical-subcortical-cerebellar subnetwork in defining clinical outcome extends the current biological understanding of the mechanisms associated with clinical benefits.
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23
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Overnight unilateral withdrawal of thalamic deep brain stimulation to identify reversibility of gait disturbances. Exp Neurol 2022; 355:114135. [DOI: 10.1016/j.expneurol.2022.114135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/11/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022]
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24
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Prakash P, Deuschl G, Ozinga S, Mitchell KT, Cheeran B, Larson PS, Merola A, Groppa S, Tomlinson T, Ostrem JL. Benefits and Risks of a Staged‐Bilateral VIM versus Unilateral VIM DBS for Essential Tremor. Mov Disord Clin Pract 2022; 9:775-784. [PMID: 35937489 PMCID: PMC9346253 DOI: 10.1002/mdc3.13490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/23/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Despite over 30 years of clinical experience, high‐quality studies on the efficacy of bilateral versus unilateral deep brain stimulation (DBS) of the ventral intermediate (VIM) nucleus of the thalamus for medically refractory essential tremor (ET) remain limited. Objectives To compare benefits and risks of bilateral versus unilateral VIM DBS using the largest ET DBS clinical trial dataset available to date. Methods Participants from the US St. Jude/Abbott pivotal ET DBS trial who underwent staged‐bilateral VIM implantation constituted the primary cohort in this sub‐analysis. Their assessments “on” DBS at six months after second‐side VIM DBS implantation were compared to the assessments six months after unilateral implantation. Two control cohorts of participants with unilateral implantation only were also used for between‐group comparisons. Results The primary cohort consisted of n = 38 ET patients (22M/16F; age of 65.3 ± 9.5 years). The second side VIM‐DBS resulted in a 29.6% additional improvement in the total motor CRST score (P < 0.001), with a 64.1% CRST improvement in the contralateral side (P < 0.001). An added improvement was observed in the axial tremor score (21.4%, P = 0.005), and CRST part B (24.8%, P < 0.001) score. Rate of adverse events was slightly higher after bilateral stimulation. Conclusions In the largest ET DBS study to date, staged‐bilateral VIM DBS was a highly effective treatment for ET with bilateral implantation resulting in greater reduction in total motor tremor scores when compared to unilateral stimulation alone.
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Affiliation(s)
- Prarthana Prakash
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center University of California San Francisco CA United States
| | - Guenther Deuschl
- Department of Neurology, Universitatsklinikum Schleswig‐Holstein, Kiel Campus Christian Albrechts University Kiel Kiel Germany
| | - Sarah Ozinga
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | | | - Binith Cheeran
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | - Paul S. Larson
- Department of Neurosurgery University of Arizona Tuscon AZ
| | - Aristide Merola
- Department of Neurology, Madden Center for Parkinson Disease and other Movement Disorders Ohio State University Wexner Medical Center Columbus OH United States
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience University Medical Center of the Johannes Gutenberg‐University Mainz Mainz Germany
| | - Tucker Tomlinson
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | - Jill L. Ostrem
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center University of California San Francisco CA United States
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25
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Chandra V, Hilliard JD, Foote KD. Deep brain stimulation for the treatment of tremor. J Neurol Sci 2022; 435:120190. [DOI: 10.1016/j.jns.2022.120190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 01/15/2023]
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26
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Pozzi NG, Isaias IU. Adaptive deep brain stimulation: Retuning Parkinson's disease. HANDBOOK OF CLINICAL NEUROLOGY 2022; 184:273-284. [PMID: 35034741 DOI: 10.1016/b978-0-12-819410-2.00015-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A brain-machine interface represents a promising therapeutic avenue for the treatment of many neurologic conditions. Deep brain stimulation (DBS) is an invasive, neuro-modulatory tool that can improve different neurologic disorders by delivering electric stimulation to selected brain areas. DBS is particularly successful in advanced Parkinson's disease (PD), where it allows sustained improvement of motor symptoms. However, this approach is still poorly standardized, with variable clinical outcomes. To achieve an optimal therapeutic effect, novel adaptive DBS (aDBS) systems are being developed. These devices operate by adapting stimulation parameters in response to an input signal that can represent symptoms, motor activity, or other behavioral features. Emerging evidence suggests greater efficacy with fewer adverse effects during aDBS compared with conventional DBS. We address this topic by discussing the basics principles of aDBS, reviewing current evidence, and tackling the many challenges posed by aDBS for PD.
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Affiliation(s)
- Nicoló G Pozzi
- Department of Neurology, University Hospital Würzburg and Julius Maximilian University Würzburg, Würzburg, Germany
| | - Ioannis U Isaias
- Department of Neurology, University Hospital Würzburg and Julius Maximilian University Würzburg, Würzburg, Germany.
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27
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Bai Y, Yin Z, Diao Y, Hu T, Yang A, Meng F, Zhang J. Loss of long-term benefit from VIM-DBS in essential tremor: A secondary analysis of repeated measurements. CNS Neurosci Ther 2021; 28:279-288. [PMID: 34866345 PMCID: PMC8739044 DOI: 10.1111/cns.13770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 10/18/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022] Open
Abstract
AIMS Deep brain stimulation (DBS) in the ventral intermediate nucleus (Vim-DBS) is the preferred surgical therapy for essential tremor (ET). Tolerance and disease progression are considered to be the two main reasons underlying the loss of long-term efficacy of Vim-DBS. This study aimed to explore whether Vim-DBS shows long-term loss of efficacy and to evaluate the reasons for this diminished efficacy from different aspects. METHODS In a repeated-measures meta-analysis of 533 patients from 18 studies, Vim-DBS efficacy was evaluated at ≤6 months, 7-12 months, 1-3 years, and ≥4 years. The primary outcomes were the score changes in different components of the Fahn-Tolosa-Marin Tremor Rating Scale (TRS; total score, motor score, hand-function score, and activities of daily living [ADL] score). Secondary outcomes were the long-term predictive factors. RESULTS The TRS total, motor, and ADL scores showed significant deterioration with disease progression (p = 0.002, p = 0.047, and p < 0.001, respectively), while the TRS total (p < 0.001), hand-function (p = 0.036), and ADL (p = 0.004) scores indicated a significant long-term reduction in DBS efficacy, although the motor subscore indicated no loss of efficacy. Hand-function (p < 0.001) and ADL (p = 0.028) scores indicated DBS tolerance, while the TRS total and motor scores did not. Stimulation frequency and preoperative score were predictive factors for long-term results. CONCLUSION This study provides level 3a evidence that long-term Vim-DBS is effective in controlling motor symptoms without waning benefits. The efficacy reduction for hand function was caused by DBS tolerance, while that for ADL was caused by DBS tolerance and disease progression. More attention should be given to actual functional recovery rather than changes in motor scores in patients with ET.
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Affiliation(s)
- Yutong Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Zixiao Yin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Yu Diao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Tianqi Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Anchao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Fangang Meng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
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28
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Lee A, Sarva H. Approach to Tremor Disorders. Semin Neurol 2021; 41:731-743. [PMID: 34826875 DOI: 10.1055/s-0041-1726356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Tremor disorders are diverse and complex. Historical clues and examination features play a major role in diagnosing these disorders, but diagnosis can be challenging due to phenotypic overlap. Ancillary testing, such as neuroimaging or laboratory testing, is driven by the history and examination, and should be performed particularly when there are other neurological or systemic manifestations. The pathophysiology of tremor is not entirely understood, but likely involves multiple networks along with the cerebello-thalamo-cortical pathways. Treatment options include medications, botulinum toxin, surgery, and nonpharmacologic interventions utilizing physical and occupational therapies and assistive devices. Further work is needed in developing accurate diagnostic tests and better treatment options for tremor disorders.
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Affiliation(s)
- Andrea Lee
- Parkinson's Disease and Movement Disorders Institute, Division of Neurodegenerative Diseases, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Harini Sarva
- Parkinson's Disease and Movement Disorders Institute, Division of Neurodegenerative Diseases, Department of Neurology, Weill Cornell Medicine, New York, New York
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29
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Maesawa S, Nakatsubo D, Tsugawa T, Kato S, Shibata M, Takai S, Torii J, Ishizaki T, Wakabayashi T, Saito R. Techniques, Indications, and Outcomes in Magnetic Resonance-guided Focused Ultrasound Thalamotomy for Tremor. Neurol Med Chir (Tokyo) 2021; 61:629-639. [PMID: 34470990 PMCID: PMC8592814 DOI: 10.2176/nmc.ra.2021-0187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Magnetic resonance (MR)-guided focused ultrasound surgery (MRgFUS) is the latest minimally invasive stereotactic procedure, and thalamotomy using this novel modality has demonstrated its effectiveness and safety, especially for patients with essential tremor (ET) and Parkinson's disease (PD). In Japan, the application of MRgFUS to treat ET and PD has recently been covered by health insurance. Technically, the transducer with 1024 elements emits ultrasound beams, which are then focused on the target with a phase control, resulting in optimal ablation by thermal coagulation. The technical advantages of MRgFUS are continuous intraoperative monitoring of clinical symptoms and MR images and fine adjustment of the target by the steering function. Postoperative tremor control is compatible with other modalities, although long-term follow-up is necessary. The adverse effects are usually transient and acceptable. Prognostic factors for good tremor control include high temperature and large lesion size. A high skull density ratio is a factor to achieve high temperature and large lesioning, but it may not be necessary and sufficient for clinical outcomes. For patients with advanced symptoms such as bilateral tremor or head/neck tremor, deep brain stimulation may be recommended because of the adjustability of stimulation and the possibility of bilateral treatment. Patients have high expectations of MRgFUS because of its non-invasiveness. To perform this treatment safely and effectively, physicians need to understand the technological aspects, the physiological principles. To choose the appropriate modality, physicians also should recognize the clinical advantages and disadvantages of MRgFUS compared to other modalities.
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Affiliation(s)
- Satoshi Maesawa
- Brain and Mind Research Center, Nagoya University
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Daisuke Nakatsubo
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Takahiko Tsugawa
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Sachiko Kato
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Masashi Shibata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Sou Takai
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Jun Torii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Tomotaka Ishizaki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Department of Neurosurgery, Kainan Hospital
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
- Radiosurgery and Focused Ultrasound Surgery Center, Nagoya Kyoritsu Hospital
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
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30
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Roque DA, Hadar E, Zhang Y, Zou F, Murrow R. Reducing Ataxic Side Effects from Ventral Intermediate Nucleus of the Thalamus Deep Brain Stimulation Implantation in Essential Tremor: Potential Advantages of Directional Stimulation. Stereotact Funct Neurosurg 2021; 100:35-43. [PMID: 34535594 DOI: 10.1159/000518238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to retrospectively evaluate the effect of directional deep brain stimulation (DBS) on ataxia in an essential tremor patient population. MATERIALS AND METHODS A retrospective chart review of documented Scale for Assessment and Rating of Ataxia (SARA) scores were analyzed using a case-control design. All subjects we evaluated were treated at a single, tertiary care academic center. We reviewed 14 patients who underwent bilateral ventral intermediate nucleus of the thalamus (VIM) implantation with microelectrode recording, with electrodeposition and segmented contact orientation confirmed via postoperative computed tomography. The main outcome was to determine change in ataxia scores between directional versus monopolar circumferential stimulation. RESULTS Fourteen patients (9 males, median age at implantation 69 [range 63-82]) underwent surgery between October 2017 and July 2020 at the UNC Movement Disorders Center. SARA scores between directional stimulation and monopolar circumferential stimulation demonstrated a significant reduction in total scores with best possible segmented stimulation (n = 13, p < 0.0001, 95% confidence interval [CI] -3.496 to -6.789). This difference remained statistically significant even after removing the SARA tremor subscore (n = 13, p < 0.0001, 95% CI -3.155 to -6.274). In line with prior reports, SARA score changes from the preoperative state were generally worsened when applying monopolar circumferential stimulation bilaterally (n = 13, p = 0.655; 95% CI -2.836 to 4.359), but improved with directional stimulation (n = 13, p = 0.010; 95% CI -1.216 to -7.547). CONCLUSION This retrospective analysis appears to show evidence for improved outcomes through directional stimulation in bilateral VIM DBS implantation with reduction of ataxic side effects that have traditionally plagued postoperative results, all while providing optimized tremor reduction via stimulation.
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Affiliation(s)
- Daniel Alberto Roque
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eldad Hadar
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ying Zhang
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Fei Zou
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard Murrow
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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31
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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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32
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Patel B, Chiu S, Wong JK, Patterson A, Deeb W, Burns M, Zeilman P, Wagle-Shukla A, Almeida L, Okun MS, Ramirez-Zamora A. Deep brain stimulation programming strategies: segmented leads, independent current sources, and future technology. Expert Rev Med Devices 2021; 18:875-891. [PMID: 34329566 DOI: 10.1080/17434440.2021.1962286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Advances in neuromodulation and deep brain stimulation (DBS) technologies have facilitated opportunities for improved clinical benefit and side effect management. However, new technologies have added complexity to clinic-based DBS programming.Areas covered: In this article, we review basic basal ganglia physiology, proposed mechanisms of action and technical aspects of DBS. We discuss novel DBS technologies for movement disorders including the role of advanced imaging software, lead design, IPG design, novel programming techniques including directional stimulation and coordinated reset neuromodulation. Additional topics include the use of potential biomarkers, such as local field potentials, electrocorticography, and adaptive stimulation. We will also discuss future directions including optogenetically inspired DBS.Expert opinion: The introduction of DBS for the management of movement disorders has expanded treatment options. In parallel with our improved understanding of brain physiology and neuroanatomy, new technologies have emerged to address challenges associated with neuromodulation, including variable effectiveness, side-effects, and programming complexity. Advanced functional neuroanatomy, improved imaging, real-time neurophysiology, improved electrode designs, and novel programming techniques have collectively been driving improvements in DBS outcomes.
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Affiliation(s)
- Bhavana Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Shannon Chiu
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Joshua K Wong
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Addie Patterson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Wissam Deeb
- Department of Neurology, University of Massachusetts College of Medicine, Worcester, MA, USA
| | - Matthew Burns
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Pamela Zeilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Aparna Wagle-Shukla
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Leonardo Almeida
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
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33
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Peters J, Tisch S. Habituation After Deep Brain Stimulation in Tremor Syndromes: Prevalence, Risk Factors and Long-Term Outcomes. Front Neurol 2021; 12:696950. [PMID: 34413826 PMCID: PMC8368435 DOI: 10.3389/fneur.2021.696950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022] Open
Abstract
Deep brain stimulation (DBS) of the thalamus is an effective treatment for medically refractory essential, dystonic and Parkinson's tremor. It may also provide benefit in less common tremor syndromes including, post-traumatic, cerebellar, Holmes, neuropathic and orthostatic tremor. The long-term benefit of DBS in essential and dystonic tremor (ET/DT) often wanes over time, a phenomena referred to as stimulation “tolerance” or “habituation”. While habituation is generally accepted to exist, it remains controversial. Attempts to quantify habituation have revealed conflicting reports. Placebo effects, loss of micro-lesional effect, disease related progression, suboptimal stimulation and stimulation related side-effects may all contribute to the loss of sustained long-term therapeutic effect. Habituation often presents as substantial loss of initial DBS benefit occurring as early as a few months after initial stimulation; a complex and feared issue when faced in the setting of optimal electrode placement. Simply increasing stimulation current tends only to propagate tremor severity and induce stimulation related side effects. The report by Paschen and colleagues of worsening tremor scores in the “On” vs. “Off” stimulation state over time, even after accounting for “rebound” tremor, supports the concept of habituation. However, these findings have not been consistent across all studies. Chronic high intensity stimulation has been hypothesized to induce detrimental plastic effects on tremor networks, with some lines of evidence that DT and ET may be more susceptible than Parkinson's tremor to habituation. However, Tsuboi and colleague's recent longitudinal follow-up in dystonic and “pure” essential tremor suggests otherwise. Alternatively, post-mortem findings support a biological adaption to stimulation. The prevalence and etiology of habituation is still not fully understood and management remains difficult. A recent study reported that alternating thalamic stimulation parameters at weekly intervals provided improved stability of tremor control consistent with reduced habituation. In this article the available evidence for habituation after DBS for tremor syndromes is reviewed; including its prevalence, time-course, possible mechanisms; along with expected long-term outcomes for tremor and factors that may assist in predicting, preventing and managing habituation.
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Affiliation(s)
- James Peters
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Stephen Tisch
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
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Borlongan MC, Farooq J, Sadanandan N, Wang ZJ, Cozene B, Lee JY, Steinberg GK. Stem Cells for Aging-Related Disorders. Stem Cell Rev Rep 2021; 17:2054-2058. [PMID: 34374944 DOI: 10.1007/s12015-021-10222-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 12/25/2022]
Abstract
This review captures recent advances in biological and translational research on stem cells. In particular, we discuss new discoveries and concepts regarding stem cell treatment of aging-related disorders. A myriad of stem cell sources exists, from hematopoietic to mesenchymal and neural cell lineages. We examine current applications of exogenous adult bone marrow-derived stem cells as an effective and safe transplantable cell source, as well as the use of electrical stimulation to promote endogenous neurogenesis for Parkinson's disease. We also explore the potential of transplanting exogenous umbilical cord blood cells and mobilizing host resident stem cells in vascular dementia and aging. In addition, we assess the ability of small molecules to recruit resident stem cells in Alzheimer's disease. Finally, we evaluate mechanisms of action recently implicated in stem cell therapy, such as the role of long non-coding RNAs, G-protein coupled receptor 5, and NeuroD1. Our goal is to provide a synopsis of recent milestones regarding the application of stem cells in aging.
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Affiliation(s)
- Mia C Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Jeffrey Farooq
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Nadia Sadanandan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Zhen-Jie Wang
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Blaise Cozene
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Jea-Young Lee
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, 94305, USA.
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Segar DJ, Tata N, Harary M, Hayes MT, Cosgrove GR. Asleep deep brain stimulation with intraoperative magnetic resonance guidance: a single-institution experience. J Neurosurg 2021; 136:699-708. [PMID: 34359029 DOI: 10.3171/2020.12.jns202572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 12/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is traditionally performed on an awake patient with intraoperative recordings and test stimulation. DBS performed under general anesthesia with intraoperative MRI (iMRI) has demonstrated high target accuracy, reduced operative time, direct confirmation of target placement, and the ability to place electrodes without cessation of medications. The authors describe their initial experience with using iMRI to perform asleep DBS and discuss the procedural and radiological outcomes of this procedure. METHODS All DBS electrodes were implanted under general anesthesia by a single surgeon by using a neuronavigation system with 3-T iMRI guidance. Clinical outcomes, operative duration, complications, and accuracy were retrospectively analyzed. RESULTS In total, 103 patients treated from 2015 to 2019 were included, and all but 1 patient underwent bilateral implantation. Indications included Parkinson's disease (PD) (65% of patients), essential tremor (ET) (29%), dystonia (5%), and refractory epilepsy (1%). Targets included the globus pallidus pars internus (12.62% of patients), subthalamic nucleus (56.31%), ventral intermedius nucleus of the thalamus (30%), and anterior nucleus of the thalamus (1%). Technically accurate lead placement (radial error ≤ 1 mm) was obtained for 98% of leads, with a mean (95% CI) radial error of 0.50 (0.46-0.54) mm; all leads were placed with a single pass. Predicted radial error was an excellent predictor of real radial error, underestimating real error by only a mean (95% CI) of 0.16 (0.12-0.20) mm. Accuracy remained high irrespective of surgeon experience, but procedure time decreased significantly with increasing institutional and surgeon experience (p = 0.007), with a mean procedure duration of 3.65 hours. Complications included 1 case of intracranial hemorrhage (asymptomatic) and 1 case of venous infarction (symptomatic), and 2 patients had infection at the internal pulse generator site. The mean ± SD voltage was 2.92 ± 0.83 V bilaterally at 1-year follow-up. Analysis of long-term clinical efficacy demonstrated consistent postoperative improvement in clinical symptoms, as well as decreased drug doses across all indications and follow-up time points, including mean decrease in levodopa-equivalent daily dose by 53.57% (p < 0.0001) in PD patients and mean decrease in primidone dose by 61.33% (p < 0.032) in ET patients at 1-year follow-up. CONCLUSIONS A total of 205 leads were placed in 103 patients by a single surgeon under iMRI guidance with few operative complications. Operative time trended downward with increasing institutional experience, and technical accuracy of radiographic lead placement was consistently high. Asleep DBS implantation with iMRI appears to be a safe and effective alternative to standard awake procedures.
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Affiliation(s)
| | - Nalini Tata
- Departments of1Neurosurgery and.,4Department of Neurosurgery, UCLA, Los Angeles, California
| | - Maya Harary
- Departments of1Neurosurgery and.,3Northwestern Feinberg School of Medicine, Chicago, Illinois; and
| | - Michael T Hayes
- 2Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Kremer NI, Pauwels RWJ, Pozzi NG, Lange F, Roothans J, Volkmann J, Reich MM. Deep Brain Stimulation for Tremor: Update on Long-Term Outcomes, Target Considerations and Future Directions. J Clin Med 2021; 10:3468. [PMID: 34441763 PMCID: PMC8397098 DOI: 10.3390/jcm10163468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023] Open
Abstract
Deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus is one of the main advanced neurosurgical treatments for drug-resistant tremor. However, not every patient may be eligible for this procedure. Nowadays, various other functional neurosurgical procedures are available. In particular cases, radiofrequency thalamotomy, focused ultrasound and radiosurgery are proven alternatives to DBS. Besides, other DBS targets, such as the posterior subthalamic area (PSA) or the dentato-rubro-thalamic tract (DRT), may be appraised as well. In this review, the clinical characteristics and pathophysiology of tremor syndromes, as well as long-term outcomes of DBS in different targets, will be summarized. The effectiveness and safety of lesioning procedures will be discussed, and an evidence-based clinical treatment approach for patients with drug-resistant tremor will be presented. Lastly, the future directions in the treatment of severe tremor syndromes will be elaborated.
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Affiliation(s)
- Naomi I. Kremer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Rik W. J. Pauwels
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
| | - Nicolò G. Pozzi
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Florian Lange
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Martin M. Reich
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
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Permezel F. Brain MRI-guided focused ultrasound conceptualised as a tool for brain network intervention. J Clin Neurosci 2021; 90:370-379. [PMID: 34275578 DOI: 10.1016/j.jocn.2021.05.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 05/02/2021] [Accepted: 05/27/2021] [Indexed: 11/25/2022]
Abstract
Magnetic resonance imaging guided high intensity focused ultrasound (HIFU) has emerged as a tool offering incisionless intervention on brain tissue. The low risk and rapid recovery from this procedure, in addition to the ability to assess for clinical benefit and adverse events intraprocedurally, makes it an ideal tool for intervention upon brain networks both for clinical and research applications. This review article proposes that conceptualising brain focused ultrasound as a tool for brain network intervention and adoption of methodology to complement this approach may result in better clinical outcomes, fewer adverse events and may unveil or allow treatment opportunities not otherwise possible. A brief introduction to network neuroscience is discussed before a description of pathological brain networks is provided for a number of conditions for which MRI-guided brain HIFU intervention has been implemented. Essential Tremor is discussed as the most advanced example of MRI-guided brain HIFU intervention adoption along with the issues that present with this treatment modality compared to alternatives. The brain network intervention paradigm is proposed to overcome these issues and a number of examples of implementation of this are discussed. The ability of low intensity MRI guided focussed ultrasound to neuromoduate brain tissue without lesioning is introduced. This tool is discussed with regards to its potential clinical application as well as its potential to further our understanding of network neuroscience via its ability to interrogate brain networks without damaging tissue. Finally, a number of current clinical trials utilising brain focused ultrasound are discussed, along with the additional applications available from the utilisation of low intensity focused ultrasound.
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Affiliation(s)
- Fiona Permezel
- Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, Austin Hospital, Victoria, Australia.
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Determining an efficient deep brain stimulation target in essential tremor - Cohort study and review of the literature. Parkinsonism Relat Disord 2021; 89:54-62. [PMID: 34225135 DOI: 10.1016/j.parkreldis.2021.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is a highly efficacious treatment for essential tremor (ET). Still, the optimal anatomical target in the (sub)thalamic area is a matter of debate. The aim of this study was to determine the optimal target of DBS for ET regarding beneficial clinical outcome and impact on activities of daily living as well as stimulation-induced side effects and compare it with previously published coordinates. METHODS In 30 ET patients undergoing bilateral DBS, severity of tremor was assessed by blinded video ratings before and at 1-year follow-up with DBS ON and OFF. Tremor scores and reported side effects and volumes of tissue activated were used to create a probabilistic map of DBS efficiency and side effects. RESULTS DBS was effective both in tremor suppression as well as in improving patient reported outcomes, which were positively correlated. The "sweet spot" for tremor suppression was located inferior of the VIM in the subthalamic area, close to the superior margin of the zona incerta. The Euclidean distance of active contacts to this spot as well as to 10 of 13 spots from the literature review was predictive of individual outcome. A cluster associated with the occurrence of ataxia was located in direct vicinity of the "sweet spot". CONCLUSION Our findings suggest the highest clinical efficacy of DBS in the posterior subthalamic area, lining up with previously published targets likely representing the dentato-rubro-thalamic tract. Side effects may not necessarily indicate lead misplacement, but should encourage clinicians to employ novel DBS programing options.
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Abstract
Deep brain stimulation (DBS) is the most commonly used surgical treatment for drug-refractory movement disorders such as tremor and dystonia. Appropriate patient selection along with target selection is important to ensure optimal outcome without complications. This review summarizes the recent literature regarding the mechanism of action, indications, outcome, and complications of DBS in tremor and dystonia. A comparison with other modalities of surgical interventions is discussed along with a note of the recent advances in technology. Future research needs to be directed to understand the underlying etiopathogenesis of the disease and the way in which DBS modulates the intracranial abnormal networks.
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Affiliation(s)
- Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Kim MJ, Chang KW, Park SH, Chang WS, Jung HH, Chang JW. Stimulation-Induced Side Effects of Deep Brain Stimulation in the Ventralis Intermedius and Posterior Subthalamic Area for Essential Tremor. Front Neurol 2021; 12:678592. [PMID: 34177784 PMCID: PMC8220085 DOI: 10.3389/fneur.2021.678592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/03/2021] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation (DBS) targeting the ventralis intermedius (VIM) nucleus of the thalamus and the posterior subthalamic area (PSA) has been shown to be an effective treatment for essential tremor (ET). The aim of this study was to compare the stimulation-induced side effects of DBS targeting the VIM and PSA using a single electrode. Patients with medication-refractory ET who underwent DBS electrode implantation between July 2011 and October 2020 using a surgical technique that simultaneously targets the VIM and PSA with a single electrode were enrolled in this study. A total of 93 patients with ET who had 115 implanted DBS electrodes (71 unilateral and 22 bilateral) were enrolled. The Clinical Rating Scale for Tremor (CRST) subscores improved from 20.0 preoperatively to 4.3 (78.5% reduction) at 6 months, 6.3 (68.5% reduction) at 1 year, and 6.5 (67.5% reduction) at 2 years postoperation. The best clinical effect was achieved in the PSA at significantly lower stimulation amplitudes. Gait disturbance and clumsiness in the leg was found in 13 patients (14.0%) upon stimulation of the PSA and in significantly few patients upon stimulation of the VIM (p = 0.0002). Fourteen patients (15.1%) experienced dysarthria when the VIM was stimulated; this number was significantly more than that with PSA stimulation (p = 0.0233). Transient paresthesia occurred in 13 patients (14.0%) after PSA stimulation and in six patients (6.5%) after VIM stimulation. Gait disturbance and dysarthria were significantly more prevalent in patients undergoing bilateral DBS than in those undergoing unilateral DBS (p = 0.00112 and p = 0.0011, respectively). Paresthesia resolved either after reducing the amplitude or switching to bipolar stimulation. However, to control gait disturbance and dysarthria, some loss of optimal tremor control was necessary at that particular electrode contact. In the present study, the most common stimulation-induced side effect associated with VIM DBS was dysarthria, while that associated with PSA DBS was gait disturbance. Significantly, more side effects were associated with bilateral DBS than with unilateral DBS. Therefore, changing active DBS contacts to simultaneous targeting of the VIM and PSA may be especially helpful for ameliorating stimulation-induced side effects.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| | - Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - So Hee Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Duchet B, Weerasinghe G, Bick C, Bogacz R. Optimizing deep brain stimulation based on isostable amplitude in essential tremor patient models. J Neural Eng 2021; 18:046023. [PMID: 33821809 PMCID: PMC7610712 DOI: 10.1088/1741-2552/abd90d] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Deep brain stimulation is a treatment for medically refractory essential tremor. To improve the therapy, closed-loop approaches are designed to deliver stimulation according to the system's state, which is constantly monitored by recording a pathological signal associated with symptoms (e.g. brain signal or limb tremor). Since the space of possible closed-loop stimulation strategies is vast and cannot be fully explored experimentally, how to stimulate according to the state should be informed by modeling. A typical modeling goal is to design a stimulation strategy that aims to maximally reduce the Hilbert amplitude of the pathological signal in order to minimize symptoms. Isostables provide a notion of amplitude related to convergence time to the attractor, which can be beneficial in model-based control problems. However, how isostable and Hilbert amplitudes compare when optimizing the amplitude response to stimulation in models constrained by data is unknown. APPROACH We formulate a simple closed-loop stimulation strategy based on models previously fitted to phase-locked deep brain stimulation data from essential tremor patients. We compare the performance of this strategy in suppressing oscillatory power when based on Hilbert amplitude and when based on isostable amplitude. We also compare performance to phase-locked stimulation and open-loop high-frequency stimulation. MAIN RESULTS For our closed-loop phase space stimulation strategy, stimulation based on isostable amplitude is significantly more effective than stimulation based on Hilbert amplitude when amplitude field computation time is limited to minutes. Performance is similar when there are no constraints, however constraints on computation time are expected in clinical applications. Even when computation time is limited to minutes, closed-loop phase space stimulation based on isostable amplitude is advantageous compared to phase-locked stimulation, and is more efficient than high-frequency stimulation. SIGNIFICANCE Our results suggest a potential benefit to using isostable amplitude more broadly for model-based optimization of stimulation in neurological disorders.
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Affiliation(s)
- Benoit Duchet
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom. MRC Brain Network Dynamics Unit, University of Oxford, Oxford, United Kingdom
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Rammo RA, Ozinga SJ, White A, Nagel SJ, Machado AG, Pallavaram S, Cheeran BJ, Walter BL. Directional Stimulation in Parkinson's Disease and Essential Tremor: The Cleveland Clinic Experience. Neuromodulation 2021; 25:829-835. [PMID: 33733515 DOI: 10.1111/ner.13374] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/18/2021] [Accepted: 02/01/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess use of directional stimulation in Parkinson's disease and essential tremor patients programmed in routine clinical care. MATERIALS AND METHODS Patients with Parkinson's disease or essential tremor implanted at Cleveland Clinic with a directional deep brain stimulation (DBS) system from November 2017 to October 2019 were included in this retrospective case series. Omnidirectional was compared against directional stimulation using therapeutic current strength, therapeutic window percentage, and total electrical energy delivered as outcome variables. RESULTS Fifty-seven Parkinson's disease patients (36 males) were implanted in the subthalamic nucleus (105 leads) and 33 essential tremor patients (19 males) were implanted in the ventral intermediate nucleus of the thalamus (52 leads). Seventy-four percent of patients with subthalamic stimulation (65% of leads) and 79% of patients with thalamic stimulation (79% of leads) were programmed with directional stimulation for their stable settings. Forty-six percent of subthalamic leads and 69% of thalamic leads were programmed on single segment activation. There was no correlation between the length of microelectrode trajectory through the STN and use of directional stimulation. CONCLUSIONS Directional programming was more common than omnidirectional programming. Substantial gains in therapeutic current strength, therapeutic window, and total electrical energy were found in subthalamic and thalamic leads programmed on directional stimulation.
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Affiliation(s)
- Richard A Rammo
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alexandra White
- Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sean J Nagel
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Benjamin L Walter
- Center For Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
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Rotter J, Atkinson J, Cutsforth-Gregory JK, Klassen BT, Miller K. Bilateral Subdural Hygromas After Deep Brain Stimulation Implantation in the Setting of Unrecognized Intracranial Hypotension. Cureus 2021; 13:e13018. [PMID: 33680583 PMCID: PMC7924968 DOI: 10.7759/cureus.13018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebrospinal fluid (CSF)-venous fistulas are a recently recognized cause of spontaneous spinal CSF leak and present most commonly with Valsalva (“cough”)-exacerbated or orthostatic headaches. By inducing CSF hypotension, they cause diffuse pachymeningeal enhancement and brain sag on MRI. This unusual case demonstrates the potential for bilateral subdural hygroma development in a patient with an undiagnosed CSF-venous fistula after ventral intermediate nucleus (VIM) deep brain stimulation (DBS) implantation. A 68-year-old gentleman with medically-refractory essential tremor underwent extensive preoperative evaluation by the Mayo Clinic-Rochester DBS Committee. Initial MRI during preoperative evaluation had no evidence of CSF hypotension, but MRI performed the day before surgery demonstrated diffuse pachymeningeal enhancement. He underwent bilateral VIM DBS implantation and presented in the subacute postoperative period with bilateral subdural hygromas. Further testing identified a prominent hyperdense paraspinal vein arising from the T10/T11 nerve root, consistent with CSF-venous fistula. Even when patients undergo rigorous preoperative evaluations for surgical procedures, insidious pathologies can develop and cause unexpected postoperative complications.
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Affiliation(s)
| | | | | | | | - Kai Miller
- Neurologic Surgery, Mayo Clinic, Rochester, USA
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Dissociative Tremor Response with Pallidal Deep Brain Stimulation in Parkinson's Disease. Tremor Other Hyperkinet Mov (N Y) 2020; 10:53. [PMID: 33362947 PMCID: PMC7747761 DOI: 10.5334/tohm.568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Pallidal and subthalamic targets are commonly used for deep brain stimulation in Parkinson’s disease (PD), with similar efficacy for resting tremor control. However, neuromodulatory effects on kinetic and postural tremor in PD is less clear. Case Report: We present a 67-year-old PD patient with marked dissociative tremor response following pallidal neuromodulation. We observed excellent resting tremor suppression, but postural and kinetic tremors remained severe, requiring additional thalamic VIM stimulation for management. Discussion: Our findings illustrate the phenotypical differences in PD and differential response to diverse tremor characteristics with distinctive stimulation targets. Additional studies are necessary to understand these differences.
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Iorio-Morin C, Fomenko A, Kalia SK. Deep-Brain Stimulation for Essential Tremor and Other Tremor Syndromes: A Narrative Review of Current Targets and Clinical Outcomes. Brain Sci 2020; 10:E925. [PMID: 33271848 PMCID: PMC7761254 DOI: 10.3390/brainsci10120925] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023] Open
Abstract
Tremor is a prevalent symptom associated with multiple conditions, including essential tremor (ET), Parkinson's disease (PD), multiple sclerosis (MS), stroke and trauma. The surgical management of tremor evolved from stereotactic lesions to deep-brain stimulation (DBS), which allowed safe and reversible interference with specific neural networks. This paper reviews the current literature on DBS for tremor, starting with a detailed discussion of current tremor targets (ventral intermediate nucleus of the thalamus (Vim), prelemniscal radiations (Raprl), caudal zona incerta (Zi), thalamus (Vo) and subthalamic nucleus (STN)) and continuing with a discussion of results obtained when performing DBS in the various aforementioned tremor syndromes. Future directions for DBS research are then briefly discussed.
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Affiliation(s)
- Christian Iorio-Morin
- Christian Iorio-Morin, Division of Neurosurgery, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Anton Fomenko
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
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Giordano M, Caccavella VM, Zaed I, Foglia Manzillo L, Montano N, Olivi A, Polli FM. Comparison between deep brain stimulation and magnetic resonance-guided focused ultrasound in the treatment of essential tremor: a systematic review and pooled analysis of functional outcomes. J Neurol Neurosurg Psychiatry 2020; 91:1270-1278. [PMID: 33055140 DOI: 10.1136/jnnp-2020-323216] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
Abstract
The current gold standard surgical treatment for medication-resistant essential tremor (ET) is deep brain stimulation (DBS). However, recent advances in technologies have led to the development of incisionless techniques, such as magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy. The authors perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to compare unilateral MRgFUS thalamotomy to unilateral and bilateral DBS in the treatment of ET in terms of tremor severity and quality of life improvement. PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and SCOPUS databases were searched. 45 eligible articles, published between 1990 and 2019, were retrieved. 1202 patients were treated with DBS and 477 were treated with MRgFUS thalamotomy. Postoperative tremor improvement was greater following DBS than MRgFUS thalamotomy (p<0.001). A subgroup analysis was carried out stratifying by treatment laterality: bilateral DBS was significantly superior to both MRgFUS and unilateral DBS (p<0.001), but no significant difference was recorded between MRgFUS and unilateral DBS (p<0.198). Postoperative quality of life improvement was significantly greater following MRgFUS thalamotomy than DBS (p<0.001). Complications were differently distributed among the two groups (p<0.001). Persistent complications were significantly more common in the MRgFUS group (p=0.042). While bilateral DBS proves superior to unilateral MRgFUS thalamotomy in the treatment of ET, a subgroup analysis suggests that treatment laterality is the most significant determinant of tremor improvement, thus highlighting the importance of future investigations on bilateral staged MRgFUS thalamotomy.
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Affiliation(s)
- Martina Giordano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | | | - Ismail Zaed
- Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | - Nicola Montano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Filippo Maria Polli
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
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Petry-Schmelzer JN, Jergas H, Thies T, Steffen JK, Reker P, Dafsari HS, Mücke D, Fink GR, Visser-Vandewalle V, Dembek TA, Barbe MT. Network Fingerprint of Stimulation-Induced Speech Impairment in Essential Tremor. Ann Neurol 2020; 89:315-326. [PMID: 33201528 DOI: 10.1002/ana.25958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 10/27/2020] [Accepted: 11/08/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study was undertaken to gain insights into structural networks associated with stimulation-induced dysarthria (SID) and to predict stimulation-induced worsening of intelligibility in essential tremor patients with bilateral thalamic deep brain stimulation (DBS). METHODS Monopolar reviews were conducted in 14 essential tremor patients. Testing included determination of SID thresholds, intelligibility ratings, and a fast syllable repetition task. Volumes of tissue activated (VTAs) were calculated to identify discriminative fibers for stimulation-induced worsening of intelligibility in a structural connectome. The resulting fiber-based atlas structure was then validated in a leave-one-out design. RESULTS Fibers determined as discriminative for stimulation-induced worsening of intelligibility were mainly connected to the ipsilateral precentral gyrus as well as to both cerebellar hemispheres and the ipsilateral brain stem. In the thalamic area, they ran laterally to the thalamus and posteromedially to the subthalamic nucleus, in close proximity, mainly anterolaterally, to fibers beneficial for tremor control as published by Al-Fatly et al in 2019. The overlap of the respective clinical stimulation setting's VTAs with these fibers explained 62.4% (p < 0.001) of the variance of stimulation-induced change in intelligibility in a leave-one-out analysis. INTERPRETATION This study demonstrates that SID in essential tremor patients is associated with both motor cortex and cerebellar connectivity. Furthermore, the identified fiber-based atlas structure might contribute to future postoperative programming strategies to achieve optimal tremor control without speech impairment in essential tremor patients with thalamic DBS. ANN NEUROL 2021;89:315-326.
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Affiliation(s)
- Jan Niklas Petry-Schmelzer
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hannah Jergas
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tabea Thies
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Linguistics, Faculty of Arts and Humanities, Institue of Linguistics Phonetics, University of Cologne, Cologne, Germany
| | - Julia K Steffen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Paul Reker
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Haidar S Dafsari
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Doris Mücke
- Department of Linguistics, Faculty of Arts and Humanities, Institue of Linguistics Phonetics, University of Cologne, Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Research Center Jülich, Institute of Neuroscience and Medicine (INM-3), Cognitive Neuroscience, Jülich, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Till A Dembek
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael T Barbe
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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48
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Ibrahim MF, Beevis JC, Empson RM. Essential Tremor - A Cerebellar Driven Disorder? Neuroscience 2020; 462:262-273. [PMID: 33212218 DOI: 10.1016/j.neuroscience.2020.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 10/23/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
Abnormal tremors are the most common of all movement disorders. In this review we focus on the role of the cerebellum in Essential Tremor, a highly debilitating but poorly treated movement disorder. We propose a variety of mechanisms driving abnormal burst firing of deep cerebellar nuclei neurons as a key initiator of tremorgenesis in Essential Tremor. Targetting these mechanisms may generate more effective treatments for Essential Tremor.
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Affiliation(s)
- Mohamed Fasil Ibrahim
- Department of Physiology, School of Biomedical Sciences, University of Otago, Dunedin 9016, New Zealand.
| | - Jessica C Beevis
- Department of Physiology, School of Biomedical Sciences, University of Otago, Dunedin 9016, New Zealand
| | - Ruth M Empson
- Department of Physiology, School of Biomedical Sciences, University of Otago, Dunedin 9016, New Zealand
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Krüger MT, Avecillas-Chasin JM, Tamber MS, Heran MKS, Sandhu MK, Polyhronopoulos NE, Sarai N, Honey CR. Tremor and Quality of Life in Patients With Advanced Essential Tremor Before and After Replacing Their Standard Deep Brain Stimulation With a Directional System. Neuromodulation 2020; 24:353-360. [PMID: 33098185 DOI: 10.1111/ner.13301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/07/2020] [Accepted: 10/05/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Patients with essential tremor treated with thalamic deep brain stimulation may experience increased tremor with the progression of their disease. Initially, this can be counteracted with increased stimulation. Eventually, this may cause unwanted side-effects as the circumferential stimulation from a standard ring contact spreads into adjacent regions. Directional leads may offer a solution to this clinical problem. We aimed to compare the ability of a standard and a directional system to reduce tremor without side-effects and to improve the quality of life for patients with advanced essential tremor. MATERIALS AND METHODS Six advanced essential tremor patients with bilateral thalamic deep brain stimulation had their standard system replaced with a directional system. Tremor rating scale scores were prospectively evaluated before and after the replacement surgery. Secondary analyses of quality of life related to tremor, voice, and general health were assessed. RESULTS There was a significantly greater reduction in tremor without side-effects (p = 0.017) when using the directional system. There were improvements in tremor (p = 0.031) and voice (p = 0.037) related quality of life but not in general health for patients using optimized stimulation settings with the directional system compared to the standard system. CONCLUSIONS In this cohort of advanced essential tremor patients who no longer had ideal tremor reduction with a standard system, replacing their deep brain stimulation with a directional system significantly improved their tremor and quality of life. Up-front implantation of directional deep brain stimulation leads may provide better tremor control in those patients who progress at a later time point.
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Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, Cantonal Hospital St.Gallen, St.Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, University Medical Clinic Freiburg, Freiburg, Germany
| | - Josue M Avecillas-Chasin
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Pediatric Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Manraj K S Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Mini K Sandhu
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | | | - Natasha Sarai
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
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Wang KL, Ren Q, Chiu S, Patel B, Meng FG, Hu W, Shukla AW. Deep brain stimulation and other surgical modalities for the management of essential tremor. Expert Rev Med Devices 2020; 17:817-833. [PMID: 33081571 DOI: 10.1080/17434440.2020.1806709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Surgical treatments are considered for essential tremor (ET) when patients do not respond to oral pharmacological therapies. These treatments mainly comprise radiofrequency (RF) thalamotomy, gamma knife radiosurgery (GKRS), deep brain stimulation (DBS), and focused ultrasound (FUS) procedures. AREAS COVERED We reviewed the strengths and weaknesses of each procedure and clinical outcomes for 7 RF studies (n = 85), 11 GKRS (n = 477), 33 DBS (n = 1061), and 13 FUS studies (n = 368). A formal comparison was not possible given the heterogeneity in studies. Improvements were about 42%-90% RF, 10%-79% GKRS, 45%-83% DBS, 42%-83% FUS at short-term follow-up (<12 months) and were about 54%-82% RF, 11%-84% GKRS, 18%-92% DBS, and 42%-80% FUS at long-term follow-up (>12 months). EXPERT OPINION We found DBS with inherent advantages of being an adjustable and reversible procedure as the most frequently employed surgical procedure for control of ET symptoms. FUS is a promising procedure but has limited applicability for unilateral control of symptoms. RF is invasive, and GKRS has unpredictable delayed effects. Each of these surgical modalities has advantages and limitations that need consideration when selecting a treatment for the ET patients.
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Affiliation(s)
- Kai-Liang Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University , Beijing, China.,Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Qianwei Ren
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Shannon Chiu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Bhavana Patel
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Fan-Gang Meng
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Wei Hu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
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