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Purrer V, Pohl E, Borger V, Weiland H, Boecker H, Schmeel FC, Wüllner U. Motor and non-motor outcome in tremor dominant Parkinson's disease after MR-guided focused ultrasound thalamotomy. J Neurol 2024:10.1007/s00415-024-12469-z. [PMID: 38822147 DOI: 10.1007/s00415-024-12469-z] [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: 02/11/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an emerging technique for the treatment of severe, medication-refractory tremor syndromes. We here report motor and non-motor outcomes 6 and 12 months after unilateral MRgFUS thalamotomy in tremor-dominant Parkinson's disease (tdPD). METHODS 25 patients with tdPD underwent neuropsychological evaluation including standardized questionnaires of disability, quality of life (QoL), mood, anxiety, apathy, sleep disturbances, and cognition at baseline, 6 and 12 months after MRgFUS. Motor outcome was evaluated using the Clinical Rating Scale for Tremor (CRST) and Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). In addition, side effects and QoL of family caregivers were assessed. RESULTS 12 months after MRgFUS significant improvements were evident in the tremor subscores. Patients with concomitant rest and postural tremor showed better tremor outcomes compared to patients with predominant rest tremor. There were no differences in the non-motor assessments. No cognitive decline was observed. Side effects were mostly transient (54%) and classified as mild (62%). No changes in the caregivers' QoL could be observed. CONCLUSION We found no changes in mood, anxiety, apathy, sleep, cognition or persistent worsening of gait disturbances after unilateral MRgFUS thalamotomy in tdPD. Concomitant postural tremors responded better to treatment than predominant rest tremors.
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Affiliation(s)
- Veronika Purrer
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany.
| | - Emily Pohl
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hannah Weiland
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Henning Boecker
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Frederic Carsten Schmeel
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Ullrich Wüllner
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany
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Lefaucheur JP, Moro E, Shirota Y, Ugawa Y, Grippe T, Chen R, Benninger DH, Jabbari B, Attaripour S, Hallett M, Paulus W. Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter. Clin Neurophysiol 2024; 164:57-99. [PMID: 38852434 DOI: 10.1016/j.clinph.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/02/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Clinical Neurophysiology Unit, Henri Mondor University Hospital, AP-HP, Créteil, France; EA 4391, ENT Team, Paris-Est Créteil University, Créteil, France.
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, CHU of Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Yuichiro Shirota
- Department of Neurology, Division of Neuroscience, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikazu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Talyta Grippe
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Neuroscience Graduate Program, Federal University of Minas Gerais, Belo Horizonte, Brazil; Krembil Brain Institute, Toronto, Ontario, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada
| | - David H Benninger
- Service of Neurology, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Walter Paulus
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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Verhagen Metman L, Monje MHG, Obeso JA, Martínez-Fernández R. Focused ultrasound therapy: Back to the future. Parkinsonism Relat Disord 2024; 121:106023. [PMID: 38320923 DOI: 10.1016/j.parkreldis.2024.106023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/08/2024]
Affiliation(s)
- Leo Verhagen Metman
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Mariana H G Monje
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - José A Obeso
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain
| | - Raúl Martínez-Fernández
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain
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Ishihara BK, Hart MG, Barrick TR, Howe FA, Morgante F, Pereira EA. Radiofrequency thalamotomy for tremor produces focused and predictable lesions shown on magnetic resonance images. Brain Commun 2023; 5:fcad329. [PMID: 38075945 PMCID: PMC10710300 DOI: 10.1093/braincomms/fcad329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 10/06/2023] [Accepted: 11/28/2023] [Indexed: 02/23/2024] Open
Abstract
Radiofrequency thalamotomy is a neurosurgical management option for medically-refractory tremor. In this observational study, we evaluate the MRI features of the resultant lesion, their temporal dynamics, and how they vary depending on surgical factors. We report on lesion characteristics including size and location, as well as how these vary over time and across different MRI sequences. Data from 12 patients (2 essential tremor, 10 Parkinson's disease) who underwent unilateral radiofrequency thalamotomy for tremor were analysed. Lesion characteristics were compared across five structural sequences. Volumetric analysis of lesion features was performed at early (<5 weeks) and late (>5 months) timepoints by manual segmentation. Lesion location was determined after registration of lesions to standard space. All patients showed tremor improvement (clinical global impressions scale) postoperatively. Chronic side-effects included balance disturbances (n = 4) and worsening mobility due to parkinsonism progression (n = 1). Early lesion features including a necrotic core, cytotoxic oedema and perilesional oedema were best demarcated on T2-weighted sequences. Multiple lesions were associated with greater cytotoxic oedema compared with single lesions (T2-weighted mean volume: 537 ± 112 mm³ versus 302 ± 146 mm³, P = 0.028). Total lesion volume reduced on average by 90% between the early and late scans (T2-weighted mean volume: 918 ± 517 versus 75 ± 50 mm³, t = 3.592, P = 0.023, n = 5), with comparable volumes demonstrated at ∼6 months after surgery. Lesion volumes on susceptibility-weighted images were larger than those of T2-weighted images at later timepoints. Radiofrequency thalamotomy produces focused and predictable lesion imaging characteristics over time. T2-weighted scans distinguish between the early lesion core and oedema characteristics, while lesions may remain more visible on susceptibility-weighted images in the months following surgery. Scanning patients in the immediate postoperative period and then at 6 months is clinically meaningful for understanding the anatomical basis of the transient and permanent effects of thalamotomy.
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Affiliation(s)
- Bryony K Ishihara
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
| | - Michael G Hart
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
| | - Thomas R Barrick
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
| | - Franklyn A Howe
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
| | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
- Department of Experimental and Clinical Medicine, University of Messina, 98122 Messina, Italy
| | - Erlick A Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George’s, University of London, London SW17 0RE, UK
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Taranta V, Saporito G, Ornello R, Splendiani A, Bruno F, Sucapane P, Masciocchi C, Marinangeli F, Cacchio A, Di Cesare E, Pistoia F. Magnetic Resonance-guided Focused Ultrasound thalamotomy for refractory neuropathic pain: a systematic review and critical appraisal of current knowledge. Ther Adv Neurol Disord 2023; 16:17562864231180729. [PMID: 37363184 PMCID: PMC10286169 DOI: 10.1177/17562864231180729] [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] [Received: 03/08/2023] [Accepted: 05/17/2023] [Indexed: 06/28/2023] Open
Abstract
Background Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an innovative therapeutical approach for medically refractory tremor. It is currently under investigation for other neurological diseases including refractory neuropathic pain (NP). Objective The objective of this systematic review is to analyze available evidence about the effectiveness and safety profile of MRgFUS in the treatment of refractory NP. Methods Eligible studies were identified by searching published studies in PubMed and Scopus databases from inception to December 2022 and by identifying ongoing studies registered on the clinicaltrials.gov website. The study was registered in PROSPERO (ID: CRD42021277154). Results We found three published observational studies and nine ongoing studies. In published studies, the involved population ranged from 8 to 46 patients with overall 66 patients being included with NP or trigeminal neuralgia. The target lesion was in the posterior part of the central lateral nucleus of the thalamus, bilaterally. Outcomes were assessed at different times through the Visual Analog Scale, showing a variable degree of improvement. Adverse events were rare, mild, and transient (vertigo, paresthesias, and dysesthesias) with intracerebral bleeding being reported as major adverse event in one case only. Among ongoing studies, we found three prospective, randomized, sham-controlled, crossover trials (RCTs) and six observational studies. Inclusion criteria are previous failure of more than three pharmacological treatments and NP duration longer than 6 months. The thalamus is the main proposed target and measured outcomes are accuracy of the procedure and pain relief, with a follow-up period ranging from 1 week to 1 year. Conclusion This systematic review suggests that, although high-quality studies are lacking, available evidence endorses the effectiveness and safety of MRgFUS in the management of NP. Ongoing RCTs will provide more robust data to understand benefits and risks of the procedure. Registration PROSPERO (ID: CRD42021277154).
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Affiliation(s)
- Valentina Taranta
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Gennaro Saporito
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Franco Marinangeli
- Department of Clinical Medicine, Public Health, Life Sciences and Environment Life, University of L’Aquila, L’Aquila, Italy
| | - Angelo Cacchio
- Department of Clinical Medicine, Public Health, Life Sciences and Environment Life, University of L’Aquila, L’Aquila, Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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Stefani A, Pierantozzi M, Cardarelli S, Stefani L, Cerroni R, Conti M, Garasto E, Mercuri NB, Marini C, Sucapane P. Neurotrophins as Therapeutic Agents for Parkinson’s Disease; New Chances From Focused Ultrasound? Front Neurosci 2022; 16:846681. [PMID: 35401084 PMCID: PMC8990810 DOI: 10.3389/fnins.2022.846681] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/31/2022] [Indexed: 01/02/2023] Open
Abstract
Magnetic Resonance–guided Focused Ultrasound (MRgFUS) represents an effective micro-lesioning approach to target pharmaco-resistant tremor, mostly in patients afflicted by essential tremor (ET) and/or Parkinson’s disease (PD). So far, experimental protocols are verifying the clinical extension to other facets of the movement disorder galaxy (i.e., internal pallidus for disabling dyskinesias). Aside from those neurosurgical options, one of the most intriguing opportunities of this technique relies on its capability to remedy the impermeability of blood–brain barrier (BBB). Temporary BBB opening through low-intensity focused ultrasound turned out to be safe and feasible in patients with PD, Alzheimer’s disease, and amyotrophic lateral sclerosis. As a mere consequence of the procedures, some groups described even reversible but significant mild cognitive amelioration, up to hippocampal neurogenesis partially associated to the increased of endogenous brain-derived neurotrophic factor (BDNF). A further development elevates MRgFUS to the status of therapeutic tool for drug delivery of putative neurorestorative therapies. Since 2012, FUS-assisted intravenous administration of BDNF or neurturin allowed hippocampal or striatal delivery. Experimental studies emphasized synergistic modalities. In a rodent model for Huntington’s disease, engineered liposomes can carry glial cell line–derived neurotrophic factor (GDNF) plasmid DNA (GDNFp) to form a GDNFp-liposome (GDNFp-LPs) complex through pulsed FUS exposures with microbubbles; in a subacute MPTP-PD model, the combination of intravenous administration of neurotrophic factors (either through protein or gene delivery) plus FUS did curb nigrostriatal degeneration. Here, we explore these arguments, focusing on the current, translational application of neurotrophins in neurodegenerative diseases.
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Affiliation(s)
- Alessandro Stefani
- Department of System Medicine, Parkinson Center, University Tor Vergata, Rome, Italy
- *Correspondence: Alessandro Stefani,
| | | | - Silvia Cardarelli
- Department of System Medicine, Parkinson Center, University Tor Vergata, Rome, Italy
| | - Lucrezia Stefani
- Department of System Medicine, Parkinson Center, University Tor Vergata, Rome, Italy
| | - Rocco Cerroni
- Department of System Medicine, Parkinson Center, University Tor Vergata, Rome, Italy
| | - Matteo Conti
- Department of System Medicine, UOC Neurology, University Tor Vergata, Rome, Italy
| | - Elena Garasto
- Department of System Medicine, UOC Neurology, University Tor Vergata, Rome, Italy
| | - Nicola B. Mercuri
- Department of System Medicine, UOC Neurology, University Tor Vergata, Rome, Italy
| | - Carmine Marini
- UOC Neurology and Stroke Unit, University of L’Aquila, L’Aquila, Italy
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Mensah-Brown KG, Yang AI, Hitti FL, Henry L, Heman-Ackah SM, Chaibainou H, Baltuch GH. Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor Under General Anesthesia: Technical Note. Oper Neurosurg (Hagerstown) 2022; 22:255-260. [PMID: 35147587 DOI: 10.1227/ons.0000000000000119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is an incisionless therapy for the treatment of medication-resistant essential tremor. Although its safety and efficacy has been demonstrated, MRgFUS is typically performed with the patient awake, with intraprocedural neurological assessments to guide lesioning. OBJECTIVE To report the first case of MRgFUS thalamotomy under general anesthesia in a patient whose medical comorbidities prohibit him from being in a supine position without a secured airway. METHODS The dentatorubrothalamic tract was directly targeted. Two sonications reaching lesional temperatures (≥54°C) were delivered without any complications. RESULTS Lesioning was confirmed on intraoperative magnetic resonance imaging, and the patient experienced 89% improvement in his tremor postoperatively. CONCLUSION This demonstrates the safety and feasibility of MRgFUS thalamotomy under general anesthesia without the benefit of intraprocedural neurological assessments.
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Affiliation(s)
- Kobina G Mensah-Brown
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew I Yang
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frederick L Hitti
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sabrina M Heman-Ackah
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hanane Chaibainou
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon H Baltuch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Binder DK, Shah BB, Elias WJ. Focused ultrasound and other lesioning in the treatment of tremor. J Neurol Sci 2022; 435:120193. [DOI: 10.1016/j.jns.2022.120193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/24/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
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