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Gopinath G, Scantlebury N, Sewell IJ, Rohringer CR, Sivadas S, McSweeney M, Boshmaf SZ, Lam B, Hamani C, Abrahao A, Schwartz ML, Lipsman N, Rabin JS. Changes in Caregiver Burden Following Unilateral Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor. Mov Disord Clin Pract 2024. [PMID: 38576099 DOI: 10.1002/mdc3.14034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/11/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024] Open
Affiliation(s)
- Georgia Gopinath
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Nadia Scantlebury
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Isabella J Sewell
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Camryn R Rohringer
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Shayan Sivadas
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Melissa McSweeney
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Silina Z Boshmaf
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Benjamin Lam
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Clement Hamani
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Agessandro Abrahao
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael L Schwartz
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jennifer S Rabin
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
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Wu BJ, Schwartz ML, Marottoli R, Adeyemo O. Medical students applying the 4Ms during their first week of school. J Am Geriatr Soc 2024. [PMID: 38472148 DOI: 10.1111/jgs.18850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Barry J Wu
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael L Schwartz
- Office of Curriculum and Department of Neurosciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richard Marottoli
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Oluwatosin Adeyemo
- Department of Obstetric, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
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Scantlebury N, Rabin JS, De Schlichting E, Hamani C, Schwartz ML, Lipsman N, Abrahao A. Reply: Evaluating the Scope and Safety of Bilateral MRgFUS Thalamotomy for Essential Tremor: A Critical Analysis. Mov Disord Clin Pract 2024; 11:320-321. [PMID: 38169118 PMCID: PMC10928345 DOI: 10.1002/mdc3.13970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Nadia Scantlebury
- Harquail Centre for Neuromodulation, Sunnybrook Research InstituteTorontoONCanada
| | - Jennifer S. Rabin
- Harquail Centre for Neuromodulation, Sunnybrook Research InstituteTorontoONCanada
- Hurvitz Brain Sciences Program, Sunnybrook Research InstituteTorontoONCanada
- Division of Neurology, Department of MedicineSunnybrook Health Sciences Centre, University of TorontoTorontoONCanada
- Rehabilitation Sciences Institute, University of TorontoTorontoONCanada
| | - Emmanuel De Schlichting
- Division of Neurosurgery, Department of SurgerySunnybrook Health Sciences Centre, University of TorontoTorontoONCanada
| | - Clement Hamani
- Harquail Centre for Neuromodulation, Sunnybrook Research InstituteTorontoONCanada
- Hurvitz Brain Sciences Program, Sunnybrook Research InstituteTorontoONCanada
- Division of Neurosurgery, Department of SurgerySunnybrook Health Sciences Centre, University of TorontoTorontoONCanada
| | - Michael L. Schwartz
- Hurvitz Brain Sciences Program, Sunnybrook Research InstituteTorontoONCanada
- Division of Neurosurgery, Department of SurgerySunnybrook Health Sciences Centre, University of TorontoTorontoONCanada
| | - Nir Lipsman
- Harquail Centre for Neuromodulation, Sunnybrook Research InstituteTorontoONCanada
- Hurvitz Brain Sciences Program, Sunnybrook Research InstituteTorontoONCanada
- Division of Neurosurgery, Department of SurgerySunnybrook Health Sciences Centre, University of TorontoTorontoONCanada
| | - Agessandro Abrahao
- Harquail Centre for Neuromodulation, Sunnybrook Research InstituteTorontoONCanada
- Hurvitz Brain Sciences Program, Sunnybrook Research InstituteTorontoONCanada
- Division of Neurology, Department of MedicineSunnybrook Health Sciences Centre, University of TorontoTorontoONCanada
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4
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Germann J, Santyr B, Boutet A, Sarica C, Chow CT, Elias GJB, Vetkas A, Yang A, Hodaie M, Fasano A, Kalia SK, Schwartz ML, Lozano AM. Comparative neural correlates of DBS and MRgFUS lesioning for tremor control in essential tremor. J Neurol Neurosurg Psychiatry 2024; 95:180-183. [PMID: 37722831 PMCID: PMC10866130 DOI: 10.1136/jnnp-2022-330795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/23/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Given high rates of early complications and non-reversibility, refined targeting is necessitated for magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for essential tremor (ET). Selection of lesion location can be informed by considering optimal stimulation area from deep brain stimulation (DBS). METHODS 118 patients with ET who received DBS (39) or MRgFUS (79) of the ventral intermediate nucleus (VIM) underwent stimulation/lesion mapping, probabilistic mapping of clinical efficacy and normative structural connectivity analysis. The efficacy maps were compared, which depict the relationship between stimulation/lesion location and clinical outcome. RESULTS Efficacy maps overlap around the VIM ventral border and encompass the dentato-rubro-thalamic tract. While the MRgFUS map extends inferiorly into the posterior subthalamic area, the DBS map spreads inside the VIM antero-superiorly. CONCLUSION Comparing the efficacy maps of DBS and MRgFUS suggests a potential alternative location for lesioning, more antero-superiorly. This may reduce complications, without sacrificing efficacy, and individualise targeting. TRIAL REGISTRATION NUMBER NCT02252380.
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Affiliation(s)
- Jurgen Germann
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Brendan Santyr
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Clement T Chow
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Gavin J B Elias
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Artur Vetkas
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Yang
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Krembil Brain Institute, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto WesternHospital, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
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5
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Scantlebury N, Rohringer CR, Rabin JS, Yunusova Y, Huang Y, Jones RM, Meng Y, Hamani C, McKinlay S, Gopinath G, Sewell IJ, Marzouqah R, McSweeney M, Lam B, Hynynen K, Schwartz ML, Lipsman N, Abrahao A. Safety of Bilateral Staged Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor. Mov Disord Clin Pract 2023; 10:1559-1561. [PMID: 37868927 PMCID: PMC10585969 DOI: 10.1002/mdc3.13882] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/09/2023] [Accepted: 08/12/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Nadia Scantlebury
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
| | - Camryn R. Rohringer
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
| | - Jennifer S. Rabin
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
- Rehabilitation Sciences Institute, University of TorontoTorontoOntarioCanada
| | - Yana Yunusova
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Rehabilitation Sciences Institute, University of TorontoTorontoOntarioCanada
- Department of Speech‐Language PathologyUniversity of TorontoTorontoOntarioCanada
- Toronto Rehabilitation Institute, University Health NetworkTorontoOntarioCanada
| | - Yuexi Huang
- Physical Sciences Platform, Sunnybrook Research InstituteTorontoOntarioCanada
| | - Ryan M. Jones
- Physical Sciences Platform, Sunnybrook Research InstituteTorontoOntarioCanada
| | - Ying Meng
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Clement Hamani
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Scotia McKinlay
- Department of Speech‐Language PathologyUniversity of TorontoTorontoOntarioCanada
- Toronto Western Hospital, University Health NetworkTorontoOntarioCanada
| | - Georgia Gopinath
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
| | - Isabella J. Sewell
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
| | - Reeman Marzouqah
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Rehabilitation Sciences Institute, University of TorontoTorontoOntarioCanada
- Department of Speech‐Language PathologyUniversity of TorontoTorontoOntarioCanada
- Toronto Rehabilitation Institute, University Health NetworkTorontoOntarioCanada
| | - Melissa McSweeney
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
| | - Benjamin Lam
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Kullervo Hynynen
- Physical Sciences Platform, Sunnybrook Research InstituteTorontoOntarioCanada
- Department of Medical BiophysicsUniversity of TorontoTorontoOntarioCanada
| | - Michael L. Schwartz
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Nir Lipsman
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Agessandro Abrahao
- Harquail Centre for NeuromodulationSunnybrook Research InstituteTorontoOntarioCanada
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoOntarioCanada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
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6
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Rabin JS, Gopinath G, McSweeney M, Scantlebury N, Rohringer CR, Sewell IJ, Abrahao A, Jones RM, Huang Y, Lam B, Hamani C, Giacobbe P, Nestor SM, Hynynen K, Schwartz ML, Lipsman N. Patient satisfaction following unilateral MR-guided focused ultrasound for tremor: Who is satisfied and who is not? Parkinsonism Relat Disord 2023; 112:105439. [PMID: 37263158 DOI: 10.1016/j.parkreldis.2023.105439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/03/2023] [Accepted: 05/07/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Jennifer S Rabin
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, M5G 1V7, Canada.
| | - Georgia Gopinath
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Melissa McSweeney
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Nadia Scantlebury
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Camryn R Rohringer
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Isabella J Sewell
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Agessandro Abrahao
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Ryan M Jones
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Yuexi Huang
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Benjamin Lam
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Clement Hamani
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Peter Giacobbe
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Sean M Nestor
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Kullervo Hynynen
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Nir Lipsman
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada; Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
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7
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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: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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8
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Rohringer CR, Sewell IJ, Gandhi S, Isen J, Davidson B, McSweeney M, Swardfager W, Scantlebury N, Swartz RH, Hamani C, Giacobbe P, Nestor SM, Yunusova Y, Lam B, Schwartz ML, Lipsman N, Abrahao A, Rabin JS. Cognitive effects of unilateral thalamotomy for tremor: a meta-analysis. Brain Commun 2022; 4:fcac287. [PMID: 36440102 PMCID: PMC9683603 DOI: 10.1093/braincomms/fcac287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/19/2022] [Accepted: 11/01/2022] [Indexed: 02/26/2024] Open
Abstract
Tremor is a debilitating symptom that can lead to functional impairment. Pharmacotherapy is often successful, but up to 50% of patients are resistant to medications or cannot tolerate side effects. Thalamotomy to the ventral intermediate nucleus of the thalamus is a surgical intervention for refractory tremor. Thalamotomy surgeries include radiofrequency and incisionless procedures, such as Gamma Knife radiosurgery and magnetic resonance-guided focused ultrasound. Cognitive changes following thalamotomy have been inconsistently reported across studies. We performed a meta-analysis to summarize the impact of unilateral thalamotomy to the ventral intermediate nucleus of the thalamus across multiple cognitive domains. We searched MEDLINE, Embase Classic, Embase and EBM Reviews for relevant studies. Neuropsychological tests were categorized into seven cognitive domains: global cognition, verbal memory, non-verbal memory, executive function, phonemic fluency, semantic fluency and visuospatial processing. We calculated standardized mean differences as Hedges' g and 95% confidence intervals of the change between pre- and postoperative cognitive scores. Pooling of standardized mean differences across studies was performed using random-effects models. Risk of bias across studies and quality of evidence for each cognitive domain were assessed with the National Institute of Health quality assessment tool and the GRADEpro Guideline Development Tool, respectively. Of the 1251 records reviewed, eight studies met inclusion criteria. We included 193 patients with essential tremor, Parkinson's disease, or multiple sclerosis in the meta-analysis. There was a small significant decline in phonemic fluency [standardized mean difference = -0.29, 95% confidence interval: (-0.52, -0.05), P = 0.017] and a trend towards a decline in semantic fluency [standardized mean difference = -0.19, 95% confidence interval: (-0.40, 0.01), P = 0.056]. No postoperative changes were observed in the other cognitive domains (P values >0.14). In secondary analyses, we restricted the analyses to studies using magnetic resonance-guided focused ultrasound given its growing popularity and more precise targeting. In those analyses, there was no evidence of cognitive decline across any domain (P values >0.37). In terms of risk of bias, five studies were rated as 'good' and three studies were rated as 'fair'. According to GRADEpro guidelines, the certainty of the effect for all cognitive domains was low. This study provides evidence that unilateral thalamotomy to the ventral intermediate nucleus of the thalamus is relatively safe from a cognitive standpoint, however, there may be a small decline in verbal fluency. Magnetic resonance-guided focused ultrasound might have a more favourable postoperative cognitive profile compared with other thalamotomy techniques.
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Affiliation(s)
- Camryn R Rohringer
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Isabella J Sewell
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Shikha Gandhi
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Jonah Isen
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Benjamin Davidson
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Melissa McSweeney
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Walter Swardfager
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Nadia Scantlebury
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Richard H Swartz
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Clement Hamani
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Peter Giacobbe
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Sean M Nestor
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Yana Yunusova
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON M5G 1V7, Canada
- Department of Speech-Language Pathology, University of Toronto, Toronto, ON M5G 1V7, Canada
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G 2A2, Canada
| | - Benjamin Lam
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Michael L Schwartz
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Nir Lipsman
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Agessandro Abrahao
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Jennifer S Rabin
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON M5G 1V7, Canada
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9
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Yamamoto K, Sarica C, Elias GJB, Boutet A, Germann J, Loh A, Joel SE, Bigioni L, Gwun D, Gramer R, Li SX, Zemmar A, Vetkas A, Algarni M, Devenyi G, Chakravarty M, Hynynen K, Scantlebury N, Schwartz ML, Lozano AM, Fasano A. Ipsilateral and axial tremor response to focused ultrasound thalamotomy for essential tremor: clinical outcomes and probabilistic mapping. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328459. [PMID: 35995551 DOI: 10.1136/jnnp-2021-328459] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND MR-guided focused ultrasound (MRgFUS) thalamotomy has been shown to be a safe and effective treatment for essential tremor (ET). OBJECTIVE To investigate the effects of MRgFUS in patients with ET with an emphasis on ipsilateral-hand and axial tremor subscores. METHODS Tremor scores and adverse effects of 100 patients treated between 2012 and 2018 were assessed at 1 week, 3, 12, and 24 months. A subgroup analysis of ipsilateral-hand tremor responders (defined as patients with ≥30% improvement at any time point) and non-responders was performed. Correlations and predictive factors for improvement were analysed. Weighted probabilistic maps of improvement were generated. RESULTS Significant improvement in axial, contralateral-hand and total tremor scores was observed at all study visits from baseline (p<0.0001). There was no significant improvement in ipsilateral subscores. A subset of patients (n=20) exhibited group-level ipsilateral-hand improvement that remained significant through all follow-ups (p<0.001). Multivariate regression analysis revealed that higher baseline scores predict better improvement in ipsilateral-hand and axial tremor. Probabilistic maps demonstrated that the lesion hotspot for axial improvement was situated more medially than that for contralateral improvement. CONCLUSION MRgFUS significantly improved axial, contralateral-hand and total tremor scores. In a subset of patients, a consistent group-level treatment effect was observed for ipsilateral-hand tremor. While ipsilateral improvement seemed to be less directly related to lesion location, a spatial relationship between lesion location and axial and contralateral improvement was observed that proved consistent with the somatotopic organisation of the ventral intermediate nucleus. TRIAL REGISTRATION NUMBERS NCT01932463, NCT01827904, and NCT02252380.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gavin J B Elias
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Jurgen Germann
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Luca Bigioni
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dave Gwun
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert Gramer
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Artur Vetkas
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Neurosurgery, University of Tartu, Tartu, Tartumaa, Estonia
| | - Musleh Algarni
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gabriel Devenyi
- Cerebral Imaging Center, Douglas Mental Health University Institute, Montreal, Quebec, Canada
- Departments of Psychiatry and Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Mallar Chakravarty
- Cerebral Imaging Center, Douglas Mental Health University Institute, Montreal, Quebec, Canada
- Departments of Psychiatry and Biological and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Nadia Scantlebury
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- Krembil Research Institute, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
- Krembil Research Institute, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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10
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Boutet A, Loh A, Germann J, Machnowska M, Scantlebury N, Vetkas A, Elias GJB, Lozano AM, Katzberg HD, Fasano A, Schwartz ML. A Cautionary Tale of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy-Induced White Matter Lesions. Mov Disord 2022; 37:1953-1955. [PMID: 35616482 DOI: 10.1002/mds.29040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Alexandre Boutet
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jurgen Germann
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matylda Machnowska
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nadia Scantlebury
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Artur Vetkas
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Neurology Clinic, Department of Neurosurgery, Tartu University Hospital, University of Tartu, Tartu, Estonia
| | - Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Hans D Katzberg
- Division of Neurology, University Health Network, Division of Neurology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Krembil Brain Institute, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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11
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Alshimemeri S, Vargas-Méndez D, Chen R, Lipsman N, Schwartz ML, Lozano AM, Fasano A. Functional tremor developing after successful MRI-guided focused ultrasound thalamotomy for essential tremor. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-327524. [PMID: 35473713 DOI: 10.1136/jnnp-2021-327524] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 02/14/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe a case of functional tremor occurring after a successful MR-guided focused ultrasound thalamotomy (MRgFUS) for essential tremor. METHODS A 71-year-old right-handed man with essential tremor was referred to us for consideration of deep brain stimulation surgery for worsening bilateral upper limb tremor after a successful left MRgFUS for essential tremor. RESULTS On clinical exam, signs compatible with a functional tremor were noted, including entertainability and suppressibility. Electrophysiological studies were consistent with essential tremor and superimposed tremor fulfilling the laboratory-supported criteria for functional tremor. DISCUSSION We describe the first reported case of a functional movement disorder occurring after successful MRgFUS procedure for essential tremor. Recognising this entity and its development after such therapeutic interventions is essential to avoid further unnecessary invasive therapies.
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Affiliation(s)
- Sohaila Alshimemeri
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN, Toronto Western Hospital, Toronto, Ontario, Canada
- Neurology Unit, Department of Medicine, King Saud University, Riyadh, Riyadh Province, Saudi Arabia
| | - Daniel Vargas-Méndez
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neurology, Clinica de Merida, Merida, Yucatan, Mexico
| | - Robert Chen
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of surgery, University of Toronto, Toronto, Ontario, Canada
| | - M L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN, Toronto Western Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
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12
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Ray JM, Wong AH, Yang TJ, Buck S, Joseph M, Bonz JW, Auerbach MA, Couturier K, Tomassoni AJ, Schwartz ML, Evans LV. Virtual Telesimulation for Medical Students During the COVID-19 Pandemic. Acad Med 2021; 96:1431-1435. [PMID: 33883398 PMCID: PMC8475640 DOI: 10.1097/acm.0000000000004129] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
PROBLEM In March 2020, the novel coronavirus 2019 (COVID-19) became a global pandemic. Medical schools around the United States faced difficult decisions, temporarily suspending hospital-based clerkship rotations for medical students due to potential shortages of personal protective equipment and a need to social distance. This decision created a need for innovative, virtual learning opportunities to support undergraduate medical education. APPROACH Educators at Yale School of Medicine developed a novel medical student curriculum converting high-fidelity, mannequin-based simulation into a fully online virtual telesimulation format. By using a virtual videoconferencing platform to deliver remote telesimulation as an immersive educational experience for widely dispersed students, this novel technology retains the experiential strengths of simulation-based learning while complying with needs for social distancing during the pandemic. The curriculum comprises simulated clinical scenarios that include live patient actors; facilitator interactions; and real-time assessment of vital signs, labs, and imaging. Each 90-minute session includes 2 sets of simulation scenarios and faculty-led teledebriefs. A team of 3 students performs the first scenario, while an additional team of 3 students observes. Teams reverse roles for the second scenario. OUTCOMES The 6-week virtual telesimulation elective enrolled the maximum 48 medical students and covered core clinical clerkship content areas. Communication patterns within the virtual telesimulation format required more deliberate turn-taking than normal conversation. Using the chat function within the videoconferencing platform allowed teams to complete simultaneous tasks. A nurse confederate provided cues not available in the virtual telesimulation format. NEXT STEPS Rapid dissemination of this program, including online webinars and live demonstration sessions with student volunteers, supports the development of similar programs at other universities. Evaluation and process improvement efforts include planned qualitative evaluation of this new format to further understand and refine the learning experience. Future work is needed to evaluate clinical skill development in this educational modality.
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Affiliation(s)
- Jessica M. Ray
- J.M. Ray is instructor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut; ORCID: https://orcid.org/0000-0003-3410-1507
| | - Ambrose H. Wong
- A.H. Wong is assistant professor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut; ORCID: https://orcid.org/0000-0001-7471-1647
| | - Thomas J. Yang
- T.J. Yang is instructor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Samuel Buck
- S. Buck is a fourth-year resident, Yale-New Haven Emergency Medicine Residency Program, New Haven, Connecticut
| | - Melissa Joseph
- M. Joseph is instructor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - James W. Bonz
- J.W. Bonz is assistant professor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marc A. Auerbach
- M.A. Auerbach is associate professor, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Katherine Couturier
- K. Couturier is instructor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Anthony J. Tomassoni
- A.J. Tomassoni is associate professor, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael L. Schwartz
- M.L. Schwartz is associate professor of neuroscience and associate dean, Curriculum, Yale School of Medicine, New Haven, Connecticut
| | - Leigh V. Evans
- L.V. Evans is associate professor, Department of Emergency Medicine and executive director, Yale Center for Medical Simulation, Yale School of Medicine, New Haven, Connecticut
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13
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Paff M, Boutet A, Germann J, Elias GJB, Chow CT, Loh A, Kucharczyk W, Fasano A, Schwartz ML, Lozano AM. Focused Ultrasound Thalamotomy Sensory Side Effects Follow the Thalamic Structural Homunculus. Neurol Clin Pract 2021; 11:e497-e503. [PMID: 34484947 DOI: 10.1212/cpj.0000000000001013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/24/2020] [Indexed: 11/15/2022]
Abstract
Objective Focused ultrasound thalamotomy is an effective treatment for tremor; however, side effects may occur. The purpose of the present study was to investigate the spatial relationship between thalamotomies and specific sensory side effects and their functional connectivity with somatosensory cortex and relationship to the medial lemniscus (ML). Methods Sensory adverse effects were categorized into 4 groups based on the location of the disturbance: face/mouth/tongue numbness/paresthesia, hand-only paresthesia, hemibody/limb paresthesia, and dysgeusia. Then, areas of significant risk (ASRs) for each category were defined using voxel-wise mass univariate analysis and overlaid on corresponding odds ratio maps. The ASR associated with the maximum risk was used as a region of interest in a normative functional connectome to determine side effect-specific functional connectivity. Finally, each ASR was overlaid on the ML derived from normative template. Results Of 103 patients, 17 developed sensory side effects after thalamotomy persisting 3 months after the procedures. Lesions producing sensory side effects extended posteriorly into the principle sensory nucleus of the thalamus or below the thalamus in the ML. The topography of sensory adverse effects followed the known somatotopy of the ML and the sensory nucleus. Functional connectivity patterns between each sensory-specific thalamic seed and the primary somatosensory areas supported the role of the middle insula in processing of gustatory information and in multisensory integration. Conclusions Distinct regions in the sensory thalamus and its afferent connections rise to specific sensory disturbances. These findings demonstrate the relationship between the sensory thalamus, ML, and bilateral sensory cortical areas.
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Affiliation(s)
- Michelle Paff
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Alexandre Boutet
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Jürgen Germann
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Gavin J B Elias
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Clement T Chow
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Aaron Loh
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Walter Kucharczyk
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Alfonso Fasano
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Michael L Schwartz
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
| | - Andres M Lozano
- University Health Network (MP, AB, JG, GJBE, CTC, AL, WK, AML), Toronto; Joint Department of Medical Imaging (AB, WK), University of Toronto; Edmond J. Safra Program in Parkinson's Disease (AF), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, and Division of Neurology (AF), University of Toronto; Krembil Brain Institute (AF); Division of Neurosurgery (MLS), Sunnybrook Health Sciences Center, University of Toronto; and Division of Neurosurgery (AML), Department of Surgery, Toronto Western Hospital and University of Toronto, Ontario, Canada
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14
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Humphreys JE, Hafler JP, Hafferty FW, Huot SJ, Angoff NR, Schwartz ML. The lived understanding of professional behavior: perspectives from three levels of seniority within a single US institution [Correction]. MedEdPublish 2021. [DOI: 10.15694/mep.2021.000157.1c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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15
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Humphreys JE, Hafler JP, Hafferty FW, Huot SJ, Angoff NR, Schwartz ML. The lived understanding of professional behavior: perspectives from three levels of seniority within a single US institution. MedEdPublish 2021. [DOI: 10.15694/mep.2021.000157.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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16
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De Vloo P, Milosevic L, Gramer RM, Dallapiazza RF, Lee DJ, Fasano A, Hutchison WD, Lozano AM, Schwartz ML, Kalia SK. Microelectrode Recording and Radiofrequency Thalamotomy following Focused Ultrasound Thalamotomy. Stereotact Funct Neurosurg 2020; 99:34-37. [PMID: 32937628 DOI: 10.1159/000510109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is a novel method for stereotactic brain lesioning and has primarily been applied for thalamotomies to treat essential tremor (ET). The electrophysiological properties of previously MRgFUS-sonicated thalamic neurons have not yet been described. We report on an ET patient who underwent an MRgFUS thalamotomy but experienced tremor recurrence. We expanded the MRgFUS-induced thalamic cavity using radiofrequency (RF), with good effect on the tremor but transient sensorimotor deficits and permanent ataxia. This is the first report of a patient undergoing RF thalamotomy after an unsuccessful MRgFUS thalamotomy. As we used microelectrode recording to guide the RF thalamotomy, we could also study for the first time the electrophysiological properties of previously sonicated thalamic neurons bordering the MRgFUS-induced cavity. These neurons displayed electrophysiological characteristics identical to those recorded from nonsonicated thalamic cells in ET patients. Hence, our findings support the widespread assumption that sonication below the necrotic threshold does not permanently alter neuronal function.
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Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada, .,Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium,
| | - Luka Milosevic
- Department of Physiology, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Robert Matthew Gramer
- Department of Neurosurgery, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Robert F Dallapiazza
- Department of Neurosurgery, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada
| | - Darrin J Lee
- Department of Neurosurgery, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Krembil Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic and Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada
| | - William D Hutchison
- Department of Physiology, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Department of Neurosurgery, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Department of Neurosurgery, Toronto Western Hospital, University Health Network Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University of Toronto, Toronto, Ontario, Canada
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17
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Kapadia AN, Elias GJB, Boutet A, Germann J, Pancholi A, Chu P, Zhong J, Fasano A, Munhoz R, Chow C, Kucharczyk W, Schwartz ML, Hodaie M, Lozano AM. Multimodal MRI for MRgFUS in essential tremor: post-treatment radiological markers of clinical outcome. J Neurol Neurosurg Psychiatry 2020; 91:921-927. [PMID: 32651242 DOI: 10.1136/jnnp-2020-322745] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/22/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND MRI-guided focused ultrasound (MRgFUS) thalamotomy is a promising non-invasive treatment option for medication-resistant essential tremor. However, it has been associated with variable efficacy and a relatively high incidence of adverse effects. OBJECTIVES To assess the evolution of radiological findings after MRgFUS thalamotomy and to evaluate their significance for clinical outcomes. METHODS Ninety-four patients who underwent MRgFUS between 2012 and 2017 were retrospectively evaluated. Lesion characteristics were assessed on routine MRI sequences, as well as with tractography. Relationships between imaging appearance, extent of white matter tract lesioning (59/94, on a 4-point scale) and clinical outcome were investigated. Recurrence was defined as >33% loss of tremor suppression at 3 months relative to day 7. RESULTS Acute lesions demonstrated blood products, surrounding oedema and peripheral diffusion restriction. The extent of dentatorubrothalamic tract (DRTT) lesioning was significantly associated with clinical improvement at 1 year (t=4.32, p=0.001). Lesion size decreased over time (180.8±91.5 mm3 at day 1 vs 19.5±19.3 mm3 at 1-year post-treatment). Higher post-treatment oedema (t=3.59, p<0.001) was associated with larger lesions at 3 months. Patients with larger lesions at day 1 demonstrated reduced rates of tremor recurrence (t=2.67, p=0.019); however, lesions over 170 mm3 trended towards greater incidence of adverse effects (sensitivity=0.60, specificity=0.63). Lesion encroachment on the medial lemniscus (Sn=1.00, Sp=0.32) and pyramidal tract (Sn=1.00, Sp=0.12) were also associated with increased adverse effects incidence. CONCLUSION Lesion size at day 1 predicts symptom recurrence, with fewer recurrences seen with larger lesions. Greater DRTT lesioning is associated with treatment efficacy. These findings may have implications for lesion targeting and extent. TRIAL REGISTRATION NUMBER NCT02252380.
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Affiliation(s)
- Anish N Kapadia
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Gavin J B Elias
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Jürgen Germann
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Aditiya Pancholi
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Powell Chu
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Jidan Zhong
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Division of Neurology, University Health Network, Toronto, Ontario, Canada
| | - Renato Munhoz
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Division of Neurology, University Health Network, Toronto, Ontario, Canada
| | - Clement Chow
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, University Health Network, Toronto, Ontario, Canada
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18
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Belitsky R, Schwartz ML, Larkin SE, Roth A. Yale University School of Medicine. Acad Med 2020; 95:S83-S86. [PMID: 33626652 DOI: 10.1097/acm.0000000000003458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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19
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Abstract
Medical schools around the world have been grappling with how to adapt undergraduate medical curricula in the face of the COVID-19 pandemic. Our institution made the decision to suspend all clinical clerkships the day before the Association of American Medical Colleges (AAMC) recommended to US medical schools a similar suspension of "medical student participation in any activities that involved patient contact." This manuscript describes the rapid evolution in our decision-making as we weighed various information, values, and priorities in the face of the emerging public health crisis. We discuss how a compromised learning environment and concerns about student, patient, and the public health led to the suspension. We also consider next steps as we move forward in this uncertain time.
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Affiliation(s)
| | - David C. Hersh
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT USA
| | - Kirsten M. Wilkins
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
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20
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Jones RM, Huang Y, Meng Y, Scantlebury N, Schwartz ML, Lipsman N, Hynynen K. Echo-Focusing in Transcranial Focused Ultrasound Thalamotomy for Essential Tremor: A Feasibility Study. Mov Disord 2020; 35:2327-2333. [PMID: 32815611 DOI: 10.1002/mds.28226] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Transcranial magnetic resonance-guided focused ultrasound (TcMRgFUS) systems currently employ computed tomography (CT)-based aberration corrections, which may provide suboptimal trans-skull focusing. OBJECTIVES The objective of this study was to evaluate a contrast agent microbubble imaging-based transcranial focusing method, echo-focusing (EF), during TcMRgFUS for essential tremor. METHODS A clinical trial of TcMRgFUS thalamotomy using EF for the treatment of essential tremor was conducted (NCT03935581; funded by InSightec [Tirat Carmel, Israel]). Patients (n = 12) were injected with Definity (Lantheus Medical Imaging, North Billerica, MA) microbubbles, and EF was performed using a research feature add-on to a commercial TcMRgFUS system (ExAblate Neuro, InSightec). Subablative thermal sonications carried out using (1) EF and (2) CT-based aberration corrections were compared via magnetic resonance thermometry, and the optimal focusing method for each patient was employed for TcMRgFUS thalamotomy. RESULTS EF aberration corrections provided increased sonication efficiency, decreased focal size, and equivalent targeting accuracy relative to CT-based focusing. EF aberration corrections were employed successfully for lesion formation in all 12 patients, 3 of whom had previously undergone unsuccessful TcMRgFUS thalamotomy via CT-based focusing. There were no adverse events related directly to the EF procedure. CONCLUSIONS EF is feasible and appears safe during TcMRgFUS thalamotomy for essential tremor and improves on the trans-skull focal quality provided by existing CT-based focusing methods. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ryan M Jones
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Yuexi Huang
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nadia Scantlebury
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kullervo Hynynen
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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21
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Meng Y, Pople CB, Kalia SK, Kalia LV, Davidson B, Bigioni L, Li DZ, Suppiah S, Mithani K, Scantlebury N, Schwartz ML, Hamani C, Lipsman N. Cost-effectiveness analysis of MR-guided focused ultrasound thalamotomy for tremor-dominant Parkinson's disease. J Neurosurg 2020; 135:273-278. [PMID: 32764177 DOI: 10.3171/2020.5.jns20692] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The development of transcranial MR-guided focused ultrasound (MRgFUS) has revitalized the practice of lesioning procedures in functional neurosurgery. Previous health economic analysis found MRgFUS thalamotomy to be a cost-effective treatment for patients with essential tremor, supporting its reimbursement. With the publication of level I evidence in support of MRgFUS thalamotomy for patients with tremor-dominant Parkinson's disease (TDPD), the authors performed a health economic comparison between MRgFUS, deep brain stimulation (DBS), and medical therapy. METHODS The authors used a decision tree model with rollback analysis and one-factor sensitivity analysis. Literature searches of MRgFUS thalamotomy and unilateral DBS of the ventrointermediate nucleus of the thalamus for TDPD were performed to determine the utility and probabilities for the model. Costs in Canadian dollars (CAD) were derived from the Schedule of Benefits and Fees in Ontario, Canada, and expert opinion on usage. RESULTS MRgFUS was associated with an expected cost of $14,831 CAD. Adding MRgFUS to continued medical therapy resulted in an incremental cost-effectiveness ratio of $30,078 per quality-adjusted life year (QALY), which remained cost-effective under various scenarios in the sensitivity analysis. Comparing DBS to MRgFUS, while DBS did not achieve the willingness-to-pay threshold ($56,503 per QALY) in the base case scenario, it did so under several scenarios in the sensitivity analysis. CONCLUSIONS MRgFUS thalamotomy is a cost-effective treatment for patients with TDPD, particularly over continued medical therapy. While MRgFUS remains competitive with DBS, the cost-effectiveness advantage is less substantial. These results will help inform the integration of this technology in the healthcare system.
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Affiliation(s)
- Ying Meng
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Christopher B Pople
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Suneil K Kalia
- 3Division of Neurosurgery, Toronto Western Hospital, University Health Network
- 4Krembil Research Institute, Toronto Western Hospital, University Health Network
| | - Lorraine V Kalia
- 4Krembil Research Institute, Toronto Western Hospital, University Health Network
- 5Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network; and
- 6Tanz Centre for Research in Neurodegenerative Diseases, and
- 7Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada
| | - Benjamin Davidson
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Luca Bigioni
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Daniel Zhengze Li
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Suganth Suppiah
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
| | - Karim Mithani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | | | | | - Clement Hamani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Nir Lipsman
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
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22
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Leydon GB, Schwartz ML. The Use of Mobile Devices to Enhance Engagement and Integration with Curricular Content. Yale J Biol Med 2020; 93:453-460. [PMID: 32874152 PMCID: PMC7448388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This perspective describes the processes, pilot designs, and deployment strategies that the Yale School of Medicine (YSM) employed when integrating iPads into the undergraduate pre-clinical medical curriculum. We also explore the multiplier effect this technology inspired in expanding the program into our clerkship curriculum with the iPad Mini and how integrating mobile technology into our existing E-systems afforded us opportunities to enter the e-book and augmented reality technology spaces. Our hope is that this perspective provides a framework that may guide other institutions researching their own technological innovations.
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Affiliation(s)
- Gary B. Leydon
- Associate Director for Technology Services, Yale University School of Medicine, New Haven, CT
| | - Michael L. Schwartz
- Associate Dean for Curriculum, Yale University School of Medicine, New Haven, CT
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23
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Paff M, Boutet A, Neudorfer C, Elias GJB, Germann J, Loh A, Kucharczyk W, Fasano A, Schwartz ML, Lozano AM. Magnetic Resonance-Guided Focused Ultrasound Thalamotomy to Treat Essential Tremor in Nonagenarians. Stereotact Funct Neurosurg 2020; 98:182-186. [PMID: 32224617 DOI: 10.1159/000506817] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/13/2020] [Indexed: 11/19/2022]
Abstract
Essential tremor (ET) is a disabling movement disorder that is most prevalent among the elderly. While deep brain stimulation surgery targeting the ventral intermediate nucleus of the thalamus is commonly used to treat ET, the most elderly patients or those with multiple medical comorbidities may not qualify as surgical candidates. Magnetic resonance-guided focused ultrasound (MRgFUS) constitutes a less invasive modality that may be used to perform thalamotomy without the need for a burr hole craniotomy. Here, we report on 2 patients over the age of 90 years who benefited significantly from MRgFUS thalamotomy to relieve their symptoms and improve their quality of life. The procedure was well tolerated and performed safely in both patients. We conclude that age should not be a limiting factor in the treatment of patients with MRgFUS.
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Affiliation(s)
| | - Alexandre Boutet
- University Health Network, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Aaron Loh
- University Health Network, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- University Health Network, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- University Health Network, Toronto, Ontario, Canada, .,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Ontario, Ontario, Canada,
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24
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Angoff NR, Schwartz ML. Readiness for Medical School: a Radical Proposal. Med Sci Educ 2020; 30:573-576. [PMID: 34457704 PMCID: PMC8368260 DOI: 10.1007/s40670-019-00858-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Readiness for medical school, like readiness for reading, includes physiological, psychological, educational, and sociological aspects of growth. Full cognitive and neurodevelopment including higher levels of adult thought order occur generally towards the ends of the third decade. Earlier patient care experiences and an understanding of the social and structural determinants of health demand some experiences in the world. We believe a requirement to prove medical school readiness should be to hold a job for a year that interfaces with the public and proves responsibility, reliability, and accountability as documented by a supervisor.
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Affiliation(s)
- Nancy R. Angoff
- Yale School of Medicine, Office of Education, Harkness D, 367 Cedar Street, New Haven, CT 06510 USA
| | - Michael L. Schwartz
- Yale School of Medicine, Office of Education, Harkness D, 367 Cedar Street, New Haven, CT 06510 USA
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25
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Muvvala SB, Schwartz ML, Petrakis I, O'Connor PG, Tetrault JM. Stitching a solution to the addiction epidemic: A longitudinal addiction curricular thread across four years of medical training. Subst Abus 2020; 41:475-479. [PMID: 31951809 DOI: 10.1080/08897077.2019.1709606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite the enormous burden and public health impact, addiction continues to be one of the most under-treated chronic diseases primarily because of the lack of adequately trained work force of medical providers. To address this issue, medical schools should greatly expand education on addiction. Methods: The six-step Kern model of curriculum development was used as a framework to create an addiction curriculum which includes didactic activities, workshop exercises, practice-based learning activities, clinical simulations, and clinical experiences. Results: The authors and other members of the addiction thread committee conducted a comprehensive needs assessment, developed curriculum goals and objectives, and worked with course and clerkship directors to develop and enhance educational strategies and implement a longitudinal curricular thread woven across all four years of medical school curriculum. Conclusion: Development and implementation of a comprehensive addiction curriculum is feasible, and this model could lay the ground work for implementation at other institutions.
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Affiliation(s)
| | - Michael L Schwartz
- Neuroscience, Yale School of Medicine (YSM), New Haven, Connecticut, USA
| | - Ismene Petrakis
- Psychiatry, Yale School of Medicine (YSM), New Haven, Connecticut, USA
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26
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Halpern CH, Santini V, Lipsman N, Lozano AM, Schwartz ML, Shah BB, Elias WJ, Cosgrove GR, Hayes MT, McDannold N, Aldrich C, Eisenberg HM, Gandhi D, Taira T, Gwinn R, Ro S, Witt J, Jung NY, Chang JW, Rosenberg J, Ghanouni P. Three-year follow-up of prospective trial of focused ultrasound thalamotomy for essential tremor. Neurology 2019; 93:e2284-e2293. [PMID: 31748250 DOI: 10.1212/wnl.0000000000008561] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/20/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) thalamotomy is effective, durable, and safe for patients with medication-refractory essential tremor (ET), we assessed clinical outcomes at 3-year follow-up of a controlled multicenter prospective trial. METHODS Outcomes were based on the Clinical Rating Scale for Tremor, including hand combined tremor-motor (scale of 0-32), functional disability (scale of 0-32), and postural tremor (scale of 0-4) scores, and total scores from the Quality of Life in Essential Tremor Questionnaire (scale of 0-100). Scores at 36 months were compared with baseline and at 6 months after treatment to assess for efficacy and durability. Adverse events were also reported. RESULTS Measured scores remained improved from baseline to 36 months (all p < 0.0001). Range of improvement from baseline was 38%-50% in hand tremor, 43%-56% in disability, 50%-75% in postural tremor, and 27%-42% in quality of life. When compared to scores at 6 months, median scores increased for hand tremor (95% confidence interval [CI] 0-2, p = 0.0098) and disability (95% CI 1-4, p = 0.0001). During the third follow-up year, all previously noted adverse events remained mild or moderate, none worsened, 2 resolved, and no new adverse events occurred. CONCLUSIONS Results at 3 years after unilateral tcMRgFUS thalamotomy for ET show continued benefit, and no progressive or delayed complications. Patients may experience mild degradation in some treatment metrics by 3 years, though improvement from baseline remains significant. CLINICALTRIALSGOV IDENTIFIER NCT01827904. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with severe ET, unilateral tcMRgFUS thalamotomy provides durable benefit after 3 years.
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Affiliation(s)
- Casey H Halpern
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea.
| | - Veronica Santini
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Nir Lipsman
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Andres M Lozano
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Michael L Schwartz
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Binit B Shah
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - W Jeff Elias
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Garth R Cosgrove
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Michael T Hayes
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Nathan McDannold
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Christina Aldrich
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Howard M Eisenberg
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Dheeraj Gandhi
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Takaomi Taira
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Ryder Gwinn
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Susie Ro
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Jennifer Witt
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Na Young Jung
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Jin Woo Chang
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Jarrett Rosenberg
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Pejman Ghanouni
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea.
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Xenos D, Kamceva M, Tomasi S, Cardin JA, Schwartz ML, Vaccarino FM. Loss of TrkB Signaling in Parvalbumin-Expressing Basket Cells Results in Network Activity Disruption and Abnormal Behavior. Cereb Cortex 2019; 28:3399-3413. [PMID: 28968898 DOI: 10.1093/cercor/bhx173] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Indexed: 12/11/2022] Open
Abstract
The GABAergic system is regulated by the brain-derived neurotrophic factor (BDNF)/Tropomyosin-related kinase B (TrkB) pathway, but the cell-intrinsic role of TrkB signaling in parvalbumin cortical interneuron development and function is unclear. We performed conditional ablation of the TrkB receptor in parvalbumin-expressing (PV) interneurons to study whether postnatal loss of TrkB in parvalbumin cells affects their survival, connectivity, spontaneous and evoked neuronal activity and behavior. Using in vivo recordings of local field potentials, we found reduced gamma oscillations in the sensory cortex of PVcre+; TrkBF/F conditional knockout mice (TrkB cKO), along with increased firing of putative excitatory neurons. There was a significant downregulation in parvalbumin neuron number in cerebral and cerebellar cortices of TrkB cKO mice. In addition, inhibitory synaptic connections between basket cells and pyramidal neurons were profoundly reduced in the neocortex of TrkB cKO mice and there was a loss of cortical volume. TrkB cKO mice also showed profound hyperactivity, stereotypies, motor deficits and learning/memory defects. Our findings demonstrate that the targeting and/or synapse formation of PV-expressing basket cells with principal excitatory neurons require TrkB signaling in parvalbumin cells. Disruption of this signaling has major consequences for parvalbumin interneuron connectivity, network dynamics, cognitive and motor behavior.
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Affiliation(s)
| | | | | | - Jessica A Cardin
- Department of Neuroscience.,Kavli Institute for Neuroscience, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, USA
| | | | - Flora M Vaccarino
- Child Study Center.,Department of Neuroscience.,Kavli Institute for Neuroscience, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, USA
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28
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Ranjan M, Elias GJB, Boutet A, Zhong J, Chu P, Germann J, Devenyi GA, Chakravarty MM, Fasano A, Hynynen K, Lipsman N, Hamani C, Kucharczyk W, Schwartz ML, Lozano AM, Hodaie M. Tractography-based targeting of the ventral intermediate nucleus: accuracy and clinical utility in MRgFUS thalamotomy. J Neurosurg 2019; 133:1002-1009. [PMID: 31561221 DOI: 10.3171/2019.6.jns19612] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tractography-based targeting of the thalamic ventral intermediate nucleus (T-VIM) is a novel method conferring patient-specific selection of VIM coordinates for tremor surgery; however, its accuracy and clinical utility in magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy compared to conventional indirect targeting has not been specifically addressed. This retrospective study sought to compare the treatment locations and potential adverse effect profiles of T-VIM with indirect targeting in a large cohort of MRgFUS thalamotomy patients. METHODS T-VIM was performed using diffusion tractography outlining the pyramidal and medial lemniscus tracts in 43 MRgFUS thalamotomy patients. T-VIM coordinates were compared with the indirect treatment coordinates used in the procedure. Thalamotomy lesions were delineated on postoperative T1-weighted images and displaced ("translated") by the anteroposterior and mediolateral difference between T-VIM and treatment coordinates. Both translated and actual lesions were normalized to standard space and subsequently overlaid with areas previously reported to be associated with an increased risk of motor and sensory adverse effects when lesioned during MRgFUS thalamotomy. RESULTS T-VIM coordinates were 2.18 mm anterior and 1.82 mm medial to the "final" indirect treatment coordinates. Translated lesions lay more squarely within the boundaries of the VIM compared to nontranslated lesions and showed significantly less overlap with areas associated with sensory adverse effects. Translated lesions overlapped less with areas associated with motor adverse effects; however, this difference was not significant. CONCLUSIONS T-VIM leads to the selection of more anterior and medial coordinates than the conventional indirect methods. Lesions moved toward these anteromedial coordinates avoid areas associated with an increased risk of motor and sensory adverse effects, suggesting that T-VIM may improve clinical outcomes.
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Affiliation(s)
- Manish Ranjan
- 1University Health Network, Toronto
- 2Krembil Brain Institute, Toronto
| | - Gavin J B Elias
- 1University Health Network, Toronto
- 2Krembil Brain Institute, Toronto
| | - Alexandre Boutet
- 1University Health Network, Toronto
- 3Joint Department of Medical Imaging, University of Toronto, Ontario
| | | | | | | | - Gabriel A Devenyi
- 4Cerebral Imaging Center, Douglas Mental Health University, McGill University; Departments of
- 5Psychiatry and
| | - M Mallar Chakravarty
- 4Cerebral Imaging Center, Douglas Mental Health University, McGill University; Departments of
- 5Psychiatry and
- 6Biological and Biomedical Engineering, McGill University, Montreal, Quebec
| | - Alfonso Fasano
- 1University Health Network, Toronto
- 2Krembil Brain Institute, Toronto
- 7The Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto
| | - Kullervo Hynynen
- 8Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto
- 9Department of Medical Biophysics, University of Toronto
- 10Institute of Biomaterials and Biomedical Engineering, University of Toronto
| | - Nir Lipsman
- 11Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto; and
- 12Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada
| | - Clement Hamani
- 11Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto; and
- 12Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada
| | - Walter Kucharczyk
- 1University Health Network, Toronto
- 3Joint Department of Medical Imaging, University of Toronto, Ontario
| | - Michael L Schwartz
- 11Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto; and
| | - Andres M Lozano
- 1University Health Network, Toronto
- 2Krembil Brain Institute, Toronto
| | - Mojgan Hodaie
- 1University Health Network, Toronto
- 2Krembil Brain Institute, Toronto
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29
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Boutet A, Ranjan M, Zhong J, Germann J, Xu D, Schwartz ML, Lipsman N, Hynynen K, Devenyi GA, Chakravarty M, Hlasny E, Llinas M, Lozano CS, Elias GJB, Chan J, Coblentz A, Fasano A, Kucharczyk W, Hodaie M, Lozano AM. Focused ultrasound thalamotomy location determines clinical benefits in patients with essential tremor. Brain 2019; 141:3405-3414. [PMID: 30452554 DOI: 10.1093/brain/awy278] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/17/2018] [Indexed: 11/13/2022] Open
Abstract
Magnetic resonance guided focused ultrasound (MRgFUS) thalamotomy is a novel and minimally invasive ablative treatment for essential tremor. The size and location of therapeutic lesions producing the optimal clinical benefits while minimizing adverse effects are not known. We examined these relationships in patients with essential tremor undergoing MRgFUS. We studied 66 patients with essential tremor who underwent MRgFUS between 2012 and 2017. We assessed the Clinical Rating Scale for Tremor (CRST) scores at 3 months after the procedure and tracked the adverse effects (sensory, motor, speech, gait, and dysmetria) 1 day (acute) and 3 months after the procedure. Clinical data associated with the postoperative Day 1 lesions were used to correlate the size and location of lesions with tremor benefit and acute adverse effects. Diffusion-weighted imaging was used to assess whether acute adverse effects were related to lesions encroaching on nearby major white matter tracts (medial lemniscus, pyramidal, and dentato-rubro-thalamic). The area of optimal tremor response at 3 months after the procedure was identified at the posterior portion of the ventral intermediate nucleus. Lesions extending beyond the posterior region of the ventral intermediate nucleus and lateral to the lateral thalamic border were associated with increased risk of acute adverse sensory and motor effects, respectively. Acute adverse effects on gait and dysmetria occurred with lesions inferolateral to the thalamus. Lesions inferolateral to the thalamus or medial to the ventral intermediate nucleus were also associated with acute adverse speech effects. Diffusion-weighted imaging revealed that lesions associated with adverse sensory and gait/dysmetria effects compromised the medial lemniscus and dentato-rubro-thalamic tracts, respectively. Lesions associated with adverse motor and speech effects encroached on the pyramidal tract. Lesions larger than 170 mm3 were associated with an increased risk of acute adverse effects. Tremor improvement and acute adverse effects of MRgFUS for essential tremor are highly dependent on the location and size of lesions. These novel findings could refine current MRgFUS treatment planning and targeting, thereby improving clinical outcomes in patients.
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Affiliation(s)
| | - Manish Ranjan
- Krembil Research Institute, Toronto, Ontario, Canada
| | - Jidan Zhong
- Krembil Research Institute, Toronto, Ontario, Canada
| | - Jurgen Germann
- Cerebral Imaging Centre, Douglas Mental Health University, McGill University, Montreal, Canada
| | - David Xu
- Krembil Research Institute, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Gabriel A Devenyi
- Cerebral Imaging Centre, Douglas Mental Health University, McGill University, Montreal, Canada.,Departments of Psychiatry, McGill University, Montreal, Canada
| | - Mallar Chakravarty
- Cerebral Imaging Centre, Douglas Mental Health University, McGill University, Montreal, Canada.,Departments of Psychiatry, McGill University, Montreal, Canada
| | | | | | | | | | - Jason Chan
- University Health Network, Toronto, ON, Canada
| | | | - Alfonso Fasano
- Krembil Research Institute, Toronto, Ontario, Canada.,Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- University Health Network, Toronto, ON, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Mojgan Hodaie
- University Health Network, Toronto, ON, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Andres M Lozano
- University Health Network, Toronto, ON, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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Scantlebury N, Meng Y, Lipsman N, Jain J, Dawson D, Schwartz ML. Change in some quality of life domains mimics change in tremor severity after ultrasound thalamotomy. Mov Disord 2019; 34:1400-1401. [PMID: 31234223 DOI: 10.1002/mds.27774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- Nadia Scantlebury
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer Jain
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Deirdre Dawson
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Rotman Research Institute, Baycrest Centre, Toronto, Ontario, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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31
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Encandela J, Zelin NS, Solotke M, Schwartz ML. Principles and Practices for Developing an Integrated Medical School Curricular Sequence About Sexual and Gender Minority Health. Teach Learn Med 2019; 31:319-334. [PMID: 30661414 DOI: 10.1080/10401334.2018.1559167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Problem: Sexual and gender minority patients face well-documented health disparities. One strategy to help overcome disparities is preparing medical trainees to competently provide care for sexual and gender minority patients. The Association of American Medical Colleges has identified professional competencies that medical students should develop to meet sexual and gender minority health needs. However, challenges in the medical education environment may hinder the adoption and implementation of curricular interventions to foster these competencies. Intervention: Our medical education community engaged in curriculum evaluation and subsequently developed a sexual and gender minority topical sequence to promote student development of these competencies. This process was guided by explicit principles and curriculum development practices. Context: This work began at the Yale University School of Medicine in 2014, shortly after the Association of American Medical Colleges published sexual and gender minority health competencies and amidst the development and implementation of a new curriculum at the institution. Impact: We identified core principles and practices to guide the development of an integrated sexual and gender minority health sequence. This process resulted in successful creation of an integrated curricular sequence. At this time, 9 new or enhanced curricular components have been adopted through our process-5 in preclinical, 3 in the clinical, and 1 in the elective, curricula-in addition to the 13 preexisting components that have been updated as appropriate. Feedback about the process from students and faculty has been overwhelmingly positive. Evaluation of curricular components and their effectiveness as an integrated sequence is ongoing. Lessons Learned: Core principles consisted of including a wide range of stakeholders to build consensus, establishing complementary student and faculty roles, using the "language of collaboration" rather than the "language of demand," presenting sexual and gender minority content in an intersectional manner whenever possible, and balancing sexual and gender minority components across the curriculum. Key practices included mapping curriculum to identify gaps; developing curriculum "pitches"; identifying early and potential later "adopters" among faculty; focusing on faculty ownership of curriculum to facilitate institutionalization; and performing ongoing tracking, assessment, and revision of curriculum.
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Affiliation(s)
- John Encandela
- a Department of Psychiatry , Yale University School of Medicine, Yale University School of Medicine , New Haven , Connecticut , USA
- b Yale Teaching and Learning Center , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Nicole S Zelin
- c Yale University School of Medicine , New Haven , Connecticut , USA
| | - Michael Solotke
- c Yale University School of Medicine , New Haven , Connecticut , USA
| | - Michael L Schwartz
- d Department of Neuroscience , Yale University School of Medicine , New Haven , Connecticut , USA
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32
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Jones RM, Kamps S, Huang Y, Scantlebury N, Lipsman N, Schwartz ML, Hynynen K. Accumulated thermal dose in MRI-guided focused ultrasound for essential tremor: repeated sonications with low focal temperatures. J Neurosurg 2019; 132:1802-1809. [PMID: 31075781 DOI: 10.3171/2019.2.jns182995] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to correlate lesion size with accumulated thermal dose (ATD) in transcranial MRI-guided focused ultrasound (MRgFUS) treatments of essential tremor with focal temperatures limited to 50°C-54°C. METHODS Seventy-five patients with medically refractory essential tremor underwent MRgFUS thalamotomy at the authors' institution. Intraoperative MR thermometry was performed to measure the induced temperature and thermal dose distributions (proton resonance frequency shift coefficient = -0.00909 ppm/°C). In 19 patients, it was not possible to raise the focal temperature above 54°C because of unfavorable skull characteristics and/or the pain associated with cranial heating. In this patient subset, sonications with focal temperatures between 50°C and 54°C were repeated (5.1 ± 1.5, mean ± standard deviation) to accumulate a sufficient thermal dose for lesion formation. The ATD profile sizes (17, 40, 100, 200, and 240 cumulative equivalent minutes at 43°C [CEM43]) calculated by combining axial MR thermometry data from individual sonications were correlated with the corresponding lesion sizes measured on axial T1-weighted (T1w) and T2-weighted (T2w) MR images acquired 1 day posttreatment. Manual corrections were applied to the MR thermometry data prior to thermal dose accumulation to compensate for off-resonance-induced spatial-shifting artifacts. RESULTS Mean lesion sizes measured on T2w MRI (5.0 ± 1.4 mm) were, on average, 28% larger than those measured on T1w MRI (3.9 ± 1.4 mm). The ATD thresholds found to provide the best correlation with lesion sizes measured on T2w and T1w MRI were 100 CEM43 (regression slope = 0.97, R2 = 0.66) and 200 CEM43 (regression slope = 0.98, R2 = 0.89), respectively, consistent with data from a previous study of MRgFUS thalamotomy via repeated sonications at higher focal temperatures (≥ 55°C). Two-way linear mixed-effects analysis revealed that dominant tremor subscores on the Fahn-Tolosa-Marin Clinical Rating Scale for Tremor (CRST) were statistically different from baseline at 3 months and 1 year posttreatment in both low-temperature (50°C-54°C) and high-temperature (≥ 55°C) patient cohorts. No significant fixed effect on the dominant tremor scores was found for the temperature cohort factor. CONCLUSIONS In transcranial MRgFUS thalamotomy for essential tremor, repeated sonications with focal temperatures between 50°C and 54°C can accumulate a sufficient thermal dose to generate lesions for clinically relevant tremor suppression up to 1 year posttreatment, and the ATD can be used to predict the size of the resulting ablation zones measured on MRI. These data will serve to guide future clinical MRgFUS brain procedures, particularly those in which focal temperatures are limited to below 55°C.
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Affiliation(s)
- Ryan M Jones
- 1Physical Sciences Platform, Sunnybrook Research Institute
| | - Shona Kamps
- 1Physical Sciences Platform, Sunnybrook Research Institute
| | - Yuexi Huang
- 1Physical Sciences Platform, Sunnybrook Research Institute
| | | | - Nir Lipsman
- 2Division of Neurosurgery, Sunnybrook Health Sciences Centre.,Departments of3Surgery and
| | - Michael L Schwartz
- 2Division of Neurosurgery, Sunnybrook Health Sciences Centre.,Departments of3Surgery and
| | - Kullervo Hynynen
- 1Physical Sciences Platform, Sunnybrook Research Institute.,4Medical Biophysics; and.,5Institute of Biomaterials and Biomedical Engineering, University of Toronto, Ontario, Canada
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Boutet A, Gwun D, Gramer R, Ranjan M, Elias GJB, Tilden D, Huang Y, Li SX, Davidson B, Lu H, Tyrrell P, Jones RM, Fasano A, Hynynen K, Kucharczyk W, Schwartz ML, Lozano AM. The relevance of skull density ratio in selecting candidates for transcranial MR-guided focused ultrasound. J Neurosurg 2019; 132:1785-1791. [PMID: 31051458 DOI: 10.3171/2019.2.jns182571] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Transcranial MR-guided focused ultrasound (MRgFUS) is a minimally invasive treatment for movement disorders. Considerable interpatient variability in skull transmission efficiency exists with the current clinical devices, which is thought to be dependent on each patient's specific skull morphology. Lower skull density ratio (SDR) values are thought to impede acoustic energy transmission across the skull, attenuating or preventing the therapeutic benefits of MRgFUS. Patients with SDR values below 0.4 have traditionally been deemed poor candidates for MRgFUS. Although considerable anecdotal evidence has suggested that SDR is a reliable determinant of procedural and clinical success, relationships between SDR and clinical outcomes have yet to be formally investigated. Moreover, as transcranial MRgFUS is becoming an increasingly widespread procedure, knowledge of SDR distribution in the general population may enable improved preoperative counseling and preparedness. METHODS A total of 98 patients who underwent MRgFUS thalamotomy at the authors' institutions between 2012 and 2018 were analyzed (cohort 1). The authors retrospectively assessed the relationships between SDR and various clinical outcomes, including tremor improvement and adverse effects, as well as procedural factors such as sonication parameters. An SDR was also prospectively obtained in 163 random emergency department patients who required a head CT scan for various clinical indications (cohort 2). Patients' age and sex were used to explore relationships with SDR. RESULTS In the MRgFUS treatment group, 17 patients with a thalamotomy lesion had an SDR below 0.4. Patients with lower SDRs required more sonication energy; however, their low SDR did not influence their clinical outcomes. In the emergency department patient group, about one-third of the patients had a low SDR (< 0.4). SDR did not correlate with age or sex. CONCLUSIONS Although lower SDR values correlated with higher energy requirements during MRgFUS thalamotomy, within the range of this study population, the SDR did not appreciably impact or provide the ability to predict the resulting clinical outcomes. Sampling of the general population suggests that age and sex have no relationship with SDR. Other variables, such as local variances in bone density, should also be carefully reviewed to build a comprehensive appraisal of a patient's suitability for MRgFUS treatment.
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Affiliation(s)
- Alexandre Boutet
- 1University Health Network, Toronto.,6Joint Department of Medical Imaging, University of Toronto
| | | | | | | | | | | | - Yuexi Huang
- 4Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto
| | | | | | - Hua Lu
- 6Joint Department of Medical Imaging, University of Toronto
| | - Pascal Tyrrell
- 5Department of Statistical Sciences, University of Toronto.,6Joint Department of Medical Imaging, University of Toronto
| | - Ryan M Jones
- 4Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto
| | - Alfonso Fasano
- 2Krembil Research Institute, Toronto.,7Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto
| | - Kullervo Hynynen
- 4Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto.,8Department of Medical Biophysics, University of Toronto.,9Institute of Biomaterials and Biomedical Engineering, University of Toronto
| | - Walter Kucharczyk
- 1University Health Network, Toronto.,6Joint Department of Medical Imaging, University of Toronto
| | - Michael L Schwartz
- 10Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada; and
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Solotke M, Sitkin NA, Schwartz ML, Encandela JA. Twelve tips for incorporating and teaching sexual and gender minority health in medical school curricula. Med Teach 2019; 41:141-146. [PMID: 29179617 DOI: 10.1080/0142159x.2017.1407867] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The World Health Organization has identified many barriers to improving the health of lesbian, gay, bisexual, and transgender (LGBT) patients, including challenges to incorporating and teaching about healthcare for such patients, which we call "sexual and gender minority" (SGM) health content. These challenges include structural and logistical barriers to incorporating SGM health content into undergraduate medical curricula, as well as lack of support in identifying high-quality pedagogical methods for teaching this material. Here, we provide twelve tips for incorporating and teaching SGM health curricular content in undergraduate medical education, including resources and strategies to support individual educators. Based on our success in developing and implementing this content, we believe that our approach can be effectively used by individual educators aiming to incorporate SGM health curricular material into their teaching, and to support individuals or groups championing the inclusion of a SGM health topical sequence in medical curricula.
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Affiliation(s)
| | | | - Michael L Schwartz
- b Office of Education , Yale University School of Medicine , New Haven , CT , USA
- c Department of Neuroscience , Yale University School of Medicine , New Haven , CT , USA
| | - John A Encandela
- d Teaching and Learning Center , Yale University School of Medicine , New Haven , CT , USA
- e Department of Psychiatry , Yale University School of Medicine , New Haven , CT , USA
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Abstract
In this thoughtful article, medical educators in various stages of their careers (resident, mid-career clinician-educators, medical school deans) reflect upon increasing reports of harassment and mistreatment of trainees by patients. In addition to providing a general overview of the limited literature on this topic, the authors describe their own experience collecting information on trainee mistreatment by patients at their institution. They explore the universal difficulty that educators face regarding how to best address this mistreatment and support both faculty and trainees. Given the current sociopolitical climate, there has never been a more urgent need to critically examine this issue. The authors call on the greater medical education community to join them in these important conversations.
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Affiliation(s)
- Kali D Cyrus
- a Department of Psychiatry Director of the Standardized Patient Program , Yale School of Medicine, The Teaching & Learning Center (TLC) , New Haven , CT , USA
| | | | - Jessica L Illuzzi
- c Vidone Birthing Center, St. Raphael Campus, Yale School of Medicine , New Haven , CT , USA
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Affiliation(s)
- J Lima
- Brown University School of Public Health, Providence, Rhode Island, United States
| | - M L Schwartz
- Brown University School of Public Health, Providence, RI, USA
| | - P L Gozalo
- Brown University School of Public Health, Providence, RI, USA
| | - M A Clark
- University of Massachusetts Medical School, Worcester, MA, USA
| | - S C Miller
- Brown University School of Public Health, Providence, RI, USA
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Schwartz ML, Clark MA, Lima JC, Miller SC. USE OF PALLIATIVE CARE CONSULTS AND END-OF-LIFE CULTURE CHANGE PRACTICES IN NURSING HOMES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M L Schwartz
- Brown University, Brookline, Massachusetts, United States
| | - M A Clark
- University of Massachusetts Medical School, Worcester, MA
| | - J C Lima
- Brown Unviersity School of Public Health, Providence RI
| | - S C Miller
- Brown Unviersity School of Public Health, Providence RI
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Miller SC, Schwartz ML, Lima JC, Shield RR, Tyler DA, Berridge CW, Lepore MJ, Clark MA. THE 2016/17 PREVALENCE OF CULTURE CHANGE PRACTICE IN U.S. NURSING HOMES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S C Miller
- Brown University, Warwick, Rhode Island, United States
| | - M L Schwartz
- Brown University School of Public Health, Providence, RI, USA
| | - J C Lima
- Brown University School of Public Health, Providence, RI, USA
| | - R R Shield
- Brown University School of Public Health, Providence, RI, USA
| | - D A Tyler
- Research Triangle Institute, Boston, MA, USA:
| | - C W Berridge
- School of Social Work, University of Washington, Seattle, WA, USA:
| | - M J Lepore
- Research Triangle Institute, Washington, DC, USA; Brown University School of Public Health, Providence, RI, USA
| | - M A Clark
- University of Massachusetts Medical School, Worcester, MA, USA
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Meng Y, Solomon B, Boutet A, Llinas M, Scantlebury N, Huang Y, Hynynen K, Hamani C, Fasano A, Lozano AM, Lipsman N, Schwartz ML. Magnetic resonance-guided focused ultrasound thalamotomy for treatment of essential tremor: A 2-year outcome study. Mov Disord 2018; 33:1647-1650. [PMID: 30288794 DOI: 10.1002/mds.99] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/19/2018] [Accepted: 06/25/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound is an emerging, minimally invasive thermoablation technique for medically refractory essential tremor. Beyond the initial year, data regarding efficacy and potential predictors of efficacy are still preliminary. OBJECTIVES The objective of this study was to assess the outcome at 2 years and the association between lesion volume and outcome 1 year after treatment. METHODS We reviewed data from 37 patients who underwent unilateral magnetic resonance-guided focused ultrasound thalamotomy, with primary outcome being dominant tremor subscore of the Clinical Rating Scale for Tremor. We used multivariable linear regression to model initial lesion volume with 1-year outcome, adjusting for other clinically relevant variables. RESULTS Although we detected a trend in loss of clinical benefit within the first year, the dominant tremor score at 2 years continued to be significantly improved (43.4%, 95% confidence interval 27.8%-59.0%) from baseline. Secondarily, initial lesion volume is significantly associated with 1-year outcome. CONCLUSION Our findings show that magnetic resonance-guided focused ultrasound thalamotomy results in sustained tremor reduction for medically refractory essential tremor even in the long term, and we highlight areas for improvement.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Benjamin Solomon
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Maheleth Llinas
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nadia Scantlebury
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yuexi Huang
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Huang Y, Lipsman N, Schwartz ML, Krishna V, Sammartino F, Lozano AM, Hynynen K. Predicting lesion size by accumulated thermal dose in MR-guided focused ultrasound for essential tremor. Med Phys 2018; 45:4704-4710. [PMID: 30098027 DOI: 10.1002/mp.13126] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 07/23/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To correlate the accumulated thermal dose (ATD) with lesion size in magnetic resonance (MR)-guided focused ultrasound (MRgFUS) thalamotomy to help guide future clinical treatments. MATERIALS AND METHODS Thirty-six patients with medication-refractory essential tremor were treated using a commercial MRgFUS brain system (ExAblate 4000, InSightec) in a 3T MR scanner (MR750, GE Healthcare). Intraoperative MR-thermometry was performed to measure the induced temperature and thermal dose distributions (thermal coefficient = -0.00909 ppm/°C). The ATD was calculated over multiple sonications with appropriate corrections for spatial-shifting artifacts. The ATD profile sizes obtained for dose values of 17, 40, 100, 200, and 240 cumulative equivalent minutes at 43°C (CEM) were correlated with the corresponding lesion sizes measured via axial T1- and T2-weighted MR images acquired 1 day post-treatment. RESULTS Of a total of 232 included sonications, 83 required corrections for off-resonance-induced spatial-shifting artifacts (correction range = [1.1,2.2] mm). The mean lesion sizes measured on T2-weighted MR images (6.2 ± 1.3 mm, mean ± SD) were 15% larger than those measured on corresponding T1-weighted MR images (5.3 ± 1.2 mm, mean ± SD). The ATD values that provided the best correlations with the measured lesion sizes on T2- and T1-weighted MR images were 100 and 200 CEM, respectively. CONCLUSION The ATD was correlated with lesion size measured 1 day following MRgFUS thalamotomy for essential tremor. These data provide useful information for predicting brain lesion size and determining treatment endpoints in future clinical MRgFUS procedures.
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Affiliation(s)
- Yuexi Huang
- Physical Sciences, Sunnybrook Research Institute, 2075, Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, 2075, Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, 2075, Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Vibhor Krishna
- Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Francesco Sammartino
- Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Kullervo Hynynen
- Physical Sciences, Sunnybrook Research Institute, 2075, Bayview Avenue, Toronto, ON M4N 3M5, Canada.,Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
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Hughes A, Huang Y, Schwartz ML, Hynynen K. The reduction in treatment efficiency at high acoustic powers during MR-guided transcranial focused ultrasound thalamotomy for Essential Tremor. Med Phys 2018; 45:2925-2936. [PMID: 29758099 DOI: 10.1002/mp.12975] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To analyze clinical data indicating a reduction in the induced energy-temperature efficiency relationship during transcranial focused ultrasound (FUS) Essential Tremor (ET) thalamotomy treatments at higher acoustic powers, establish its relationship with the spatial distribution of the focal temperature elevation, and explore its cause. METHODS A retrospective observational study of patients (n = 19) treated between July 2015 and August 2016 for (ET) by FUS thalamotomy was performed. These data were analyzed to compare the relationships between the applied power, the applied energy, the resultant peak temperature achieved in the brain, and the dispersion of the focal volume. Full ethics approval was received and all patients provided signed informed consent forms before the initiation of the study. Computer simulations, animal experiments, and clinical system tests were performed to determine the effects of skull heating, changes in brain properties and transducer acoustic output, respectively. All animal procedures were approved by the Animal Care and Use Committee and conformed to the guidelines set out by the Canadian Council on Animal Care. MATLAB was used to perform statistical analysis. RESULTS The reduction in the energy efficiency relationship during treatment correlates with the increase in size of the focal volume at higher sonication powers. A linear relationship exists showing that a decrease in treatment efficiency correlates positively with an increase in the focal size over the course of treatment (P < 0.01), supporting the hypothesis of transient skull and tissue heating causing acoustic aberrations leading to a decrease in efficiency. Changes in thermal conductivity, perfusion, absorption rates in the brain, as well as ultrasound transducer acoustic output levels were found to have minimal effects on the observed reduction in efficiency. CONCLUSIONS The reduction in energy-temperature efficiency during high-power FUS treatments correlated with observed increases in the size of the focal volume and is likely caused by transient changes in the tissue and skull during heating.
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Affiliation(s)
- Alec Hughes
- Department of Medical Biophysics, University of Toronto, 101 College St, Room 15-701, Toronto, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Room C713, 2075 Bayview Ave, Toronto, Canada
| | - Yuexi Huang
- Physical Sciences Platform, Sunnybrook Research Institute, Room C713, 2075 Bayview Ave, Toronto, Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Kullervo Hynynen
- Department of Medical Biophysics, University of Toronto, 101 College St, Room 15-701, Toronto, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Room C713, 2075 Bayview Ave, Toronto, Canada
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Schwartz ML, Yeung R, Huang Y, Lipsman N, Krishna V, Jain JD, Chapman MG, Lozano AM, Hynynen K. Skull bone marrow injury caused by MR-guided focused ultrasound for cerebral functional procedures. J Neurosurg 2018; 130:758-762. [PMID: 29726769 DOI: 10.3171/2017.11.jns17968] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE One patient for whom an MR-guided focused ultrasound (MRgFUS) pallidotomy was attempted was discovered to have multiple new skull lesions with the appearance of infarcts on the MRI scan 3 months after his attempted treatment. The authors conducted a retrospective review of the first 30 patients treated with MRgFUS to determine the incidence of skull lesions in patients undergoing these procedures and to consider possible causes. METHODS A retrospective review of the MRI scans of the first 30 patients, 1 attempted pallidotomy and 29 ventral intermediate nucleus thalamotomies, was conducted. The correlation of the mean skull density ratio (SDR) and the maximum energy applied in the production or attempted production of a brain lesion was examined. RESULTS Of 30 patients treated with MRgFUS for movement disorders, 7 were found to have new skull lesions that were not present prior to treatment and not visible on the posttreatment day 1 MRI scan. Discomfort was reported at the time of treatment by some patients with and without skull lesions. All patients with skull lesions were completely asymptomatic. There was no correlation between the mean SDR and the presence or absence of skull lesions, but the maximum energy applied with the Exablate system was significantly greater in patients with skull lesions than in those without. CONCLUSIONS It is known that local skull density, thickness, and SDR vary from location to location. Sufficient energy transfer resulting in local heating sufficient to produce a bone lesion may occur in regions of low SDR. A correlation of lesion location and local skull properties should be made in future studies.
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Affiliation(s)
| | - Robert Yeung
- 2Sunnybrook Health Sciences Centre
- Departments of3Medical Imaging and
| | - Yuexi Huang
- 4Physical Sciences Platform, Sunnybrook Research Institute; and
| | - Nir Lipsman
- 1Division of Neurosurgery and
- 2Sunnybrook Health Sciences Centre
| | - Vibhor Krishna
- 5Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | | | | | - Andres M Lozano
- 1Division of Neurosurgery and
- 7Toronto Western Hospital, Toronto, Ontario, Canada; and
| | - Kullervo Hynynen
- 4Physical Sciences Platform, Sunnybrook Research Institute; and
- 8Medical Biophysics, and
- 9Institute of Biomaterials and Biomedical Engineering, University of Toronto
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Chang JW, Park CK, Lipsman N, Schwartz ML, Ghanouni P, Henderson JM, Gwinn R, Witt J, Tierney TS, Cosgrove GR, Shah BB, Abe K, Taira T, Lozano AM, Eisenberg HM, Fishman PS, Elias WJ. A prospective trial of magnetic resonance-guided focused ultrasound thalamotomy for essential tremor: Results at the 2-year follow-up. Ann Neurol 2018; 83:107-114. [DOI: 10.1002/ana.25126] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 12/17/2017] [Accepted: 12/18/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Jin Woo Chang
- Department of Neurosurgery Yonsei University College of Medicine; Seoul South Korea
| | - Chang Kyu Park
- Department of Neurosurgery Yonsei University College of Medicine; Seoul South Korea
| | - Nir Lipsman
- Department of Neurosurgery Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Michael L. Schwartz
- Department of Neurosurgery Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Pejman Ghanouni
- Department of Radiology; Stanford University School of Medicine; Stanford CA
| | - Jaimie M. Henderson
- Department of Neurosurgery; Stanford University School of Medicine; Stanford CA
| | - Ryder Gwinn
- Department of Neurosurgery Swedish Neuroscience Institute; Seattle WA
| | - Jennifer Witt
- Department of Neurosurgery Swedish Neuroscience Institute; Seattle WA
| | - Travis S. Tierney
- Department of Neurosurgery; University of Miami School of Medicine, Nicklaus Children's Hospital; Miami FL
| | - G. Rees Cosgrove
- Department of Neurosurgery; Brigham and Women's Hospital; Boston MA
| | - Binit B. Shah
- Department of Neurology; University of Virginia Health Sciences Center; Charlottesville VA
| | - Keiichi Abe
- Department of Neurosurgery; Tokyo Women's Medical University; Tokyo Japan
| | - Takaomi Taira
- Department of Neurosurgery; Tokyo Women's Medical University; Tokyo Japan
| | - Andres M. Lozano
- Department of Neurosurgery; University of Toronto; Toronto Ontario Canada
| | | | | | - W. Jeffrey Elias
- Department of Neurosurgery; University of Virginia Health Sciences Center; Charlottesville VA
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Abstract
BACKGROUND The video-based lecture (VBL), an important component of the flipped classroom (FC) and massive open online course (MOOC) approaches to medical education, has primarily been evaluated through direct learner feedback. Evaluation may be enhanced through learner analytics (LA) - analysis of quantitative audience usage data generated by video-sharing platforms. METHODS AND RESULTS We applied LA to an experimental series of ten VBLs on electroencephalography (EEG) interpretation, uploaded to YouTube in the model of a publicly accessible MOOC. Trends in view count; total percentage of video viewed and audience retention (AR) (percentage of viewers watching at a time point compared to the initial total) were examined. The pattern of average AR decline was characterized using regression analysis, revealing a uniform linear decline in viewership for each video, with no evidence of an optimal VBL length. Segments with transient increases in AR corresponded to those focused on core concepts, indicative of content requiring more detailed evaluation. We propose a model for applying LA at four levels: global, series, video, and feedback. DISCUSSION AND CONCLUSIONS LA may be a useful tool in evaluating a VBL series. Our proposed model combines analytics data and learner self-report for comprehensive evaluation.
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Affiliation(s)
- K H Vincent Lau
- a Department of Neurology , Massachusetts General Hospital , Boston , MA , USA
| | - Pue Farooque
- b Department of Neurology , Yale School of Medicine , New Haven , CT , USA
| | - Gary Leydon
- c Department of Teaching and Learning Center , Yale School of Medicine , New Haven , CT , USA
| | - Michael L Schwartz
- d Department of Neurobiology , Yale School of Medicine , New Haven , CT , USA
- e Office of Education , Yale School of Medicine , New Haven , CT , USA
| | - R Mark Sadler
- f Department of Medicine, Division of Neurology , Dalhousie University , Halifax , Canada
| | - Jeremy J Moeller
- b Department of Neurology , Yale School of Medicine , New Haven , CT , USA
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Meng Y, Huang Y, Solomon B, Hynynen K, Scantlebury N, Schwartz ML, Lipsman N. MRI-guided Focused Ultrasound Thalamotomy for Patients with Medically-refractory Essential Tremor. J Vis Exp 2017. [PMID: 29286434 DOI: 10.3791/56365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Essential tremor (ET) is the most common type of tremor in adults. While ET does not result in decreased life expectancy, the disabilities associated with ET can have a significant impact on quality of life, mood, functional activities, and socialization. Patients suffering from ET not sufficiently treated with first line medications may be eligible for alternative strategies such as deep brain stimulation, radiofrequency ablation, and MRI guided focused ultrasound (MRgFUS). High-intensity MRgFUS is an emerging modality to treat ET, its attraction for patients being that it is noninvasive and associated with short recovery time, as patients are home the day after treatment. While MRgFUS centers are still limited, it will become important for clinicians to consider MRgFUS as a treatment alternative, particularly in the case of a patient for whom open surgery is contraindicated. This article outlines the steps of patient selection, equipment setup, sonication, and post-treatment follow-up, as well as critical steps to be aware of when performing a MRgFUS procedure.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre
| | - Yuexi Huang
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre
| | - Benjamin Solomon
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre
| | | | | | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre;
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Daniel M, Fleming A, Grochowski CO, Harnik V, Klimstra S, Morrison G, Pock A, Schwartz ML, Santen S. Why Not Wait? Eight Institutions Share Their Experiences Moving United States Medical Licensing Examination Step 1 After Core Clinical Clerkships. Acad Med 2017; 92:1515-1524. [PMID: 28422816 DOI: 10.1097/acm.0000000000001714] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The majority of medical students complete the United States Medical Licensing Examination Step 1 after their foundational sciences; however, there are compelling reasons to examine this practice. This article provides the perspectives of eight MD-granting medical schools that have moved Step 1 after the core clerkships, describing their rationale, logistics of the change, outcomes, and lessons learned. The primary reasons these institutions cite for moving Step 1 after clerkships are to foster more enduring and integrated basic science learning connected to clinical care and to better prepare students for the increasingly clinical focus of Step 1. Each school provides key features of the preclerkship and clinical curricula and details concerning taking Steps 1 and 2, to allow other schools contemplating change to understand the landscape. Most schools report an increase in aggregate Step 1 scores after the change. Despite early positive outcomes, there may be unintended consequences to later scheduling of Step 1, including relatively late student reevaluations of their career choice if Step 1 scores are not competitive in the specialty area of their choice. The score increases should be interpreted with caution: These schools may not be representative with regard to mean Step 1 scores and failure rates. Other aspects of curricular transformation and rising national Step 1 scores confound the data. Although the optimal timing of Step 1 has yet to be determined, this article summarizes the perspectives of eight schools that changed Step 1 timing, filling a gap in the literature on this important topic.
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Affiliation(s)
- Michelle Daniel
- M. Daniel is assistant dean of curriculum and assistant professor, Departments of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan. A. Fleming is associate dean for student affairs and associate professor of pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee. C.O. Grochowski is associate dean for curricular affairs, Duke University School of Medicine, Durham, North Carolina. V. Harnik is associate dean for curriculum and assistant professor, Department of Cell Biology, New York University School of Medicine, New York, New York. S. Klimstra is Ehrenkranz Associate Dean of Academic Affairs and professor of clinical psychiatry, Weill Cornell Medical College, New York, New York. G. Morrison is senior vice dean for education and professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. A. Pock is associate dean for curriculum and associate professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. M.L. Schwartz is associate dean for curriculum and associate professor, Department of Neuroscience, Yale University School of Medicine, New Haven, Connecticut. S. Santen is assistant dean for educational research and quality improvement and professor of emergency medicine and learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan
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Meng Y, Suppiah S, Mithani K, Solomon B, Schwartz ML, Lipsman N. Current and emerging brain applications of MR-guided focused ultrasound. J Ther Ultrasound 2017; 5:26. [PMID: 29034095 PMCID: PMC5629772 DOI: 10.1186/s40349-017-0105-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/28/2017] [Indexed: 12/30/2022] Open
Abstract
MRI guided focused ultrasound is an emerging technique that uses acoustic energy to noninvasively treat intracranial disorders. At high frequencies, it can be used to raise tissue temperatures and ablate discrete brain targets with sub-millimeter accuracy. This application is currently under investigation for a broad range of clinical applications, including brain tumors, movement disorders, and psychiatric conditions. At low frequencies MRI guided focused ultrasound can be used to modulate neuronal activity and in conjunction with injected microbubbles, can open the blood-brain barrier to enhance the delivery of therapeutic compounds. The last decade has seen dramatic advances in the science of MRI guided focused ultrasound, helping elucidate both its mechanisms and potential in pre-clinical models, and its translational promise across myriad clinical applications. This review provides an update of current and emerging MRI guided focused ultrasound applications for intracranial disorders and describes future directions and challenges for the field.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON Canada
| | - Suganth Suppiah
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON Canada
| | - Karim Mithani
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON Canada
| | - Benjamin Solomon
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON Canada
| | - Michael L Schwartz
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON Canada
| | - Nir Lipsman
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON Canada
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Moeller JJ, Farooque P, Leydon G, Dominguez M, Schwartz ML, Sadler RM. A Video-Based Introductory EEG Curriculum for Neurology Residents and Other EEG Learners. MedEdPORTAL 2017; 13:10570. [PMID: 30800772 PMCID: PMC6342517 DOI: 10.15766/mep_2374-8265.10570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/02/2017] [Indexed: 05/30/2023]
Abstract
INTRODUCTION It is difficult to provide standardized formal education in EEG because of time limitations and the availability of expert teachers. Video-based miniature lectures are a useful way to standardize the foundational principles of EEG and support learning during EEG/epilepsy rotations. METHODS A curriculum of 10 EEG teaching videos was developed based on concepts outlined in the Accreditation Council for Graduate Medical Education Neurology Milestones. The videos were short (6-17 minutes) and made available to residents rotating through an EEG/epilepsy rotation in two neurology residency programs. Residents were instructed to review the videos and then apply their newly learned skills during EEG reading sessions. A survey about the process was completed at the end of the year. RESULTS Twenty-one residents participated in the curriculum, and 15 (71%) responded to the survey. Two-thirds of respondents (10/15) said that they watched all of the videos, and 87% (13/15) watched at least half of the videos. All of the respondents used the videos as introductions to EEG concepts, and approximately half of respondents returned to the videos as a refresher after the rotation was over. Nearly all respondents either agreed or strongly agreed that the curriculum was a useful component of the rotation and helped them to understand difficult concepts. All strongly agreed that they would recommend the curriculum to other residents. DISCUSSION A video-based approach to EEG teaching could complement existing curricula and ensure that learners have access to foundational miniature lectures when and where they need them.
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Affiliation(s)
- Jeremy J. Moeller
- Assistant Professor and Residency Program Director, Department of Neurology, Yale School of Medicine
| | - Pue Farooque
- Assistant Professor, Department of Neurology, Yale School of Medicine
- Epilepsy Fellowship Director, Department of Neurology, Yale School of Medicine
| | - Gary Leydon
- Associate Director for Technology Services, Teaching and Learning Center, Yale School of Medicine
| | | | - Michael L. Schwartz
- Associate Professor of Neuroscience, Yale School of Medicine
- Director of Medical Studies in Neurobiology, Yale School of Medicine
- Associate Dean for Curriculum, Yale School of Medicine
| | - R. Mark Sadler
- Professor, Division of Neurology, Department of Medicine, Dalhousie University Faculty of Medicine
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Dmytriw AA, Schwartz ML, Cusimano MD, Mendes Pereira V, Krings T, Tymianski M, Radovanovic I, Agid R. Gamma Knife radiosurgery for the treatment of intracranial dural arteriovenous fistulas. Interv Neuroradiol 2016; 23:211-220. [PMID: 28156167 DOI: 10.1177/1591019916683689] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Intracranial dural arteriovenous fistulae (DAVF) may present a treatment challenge. Endovascular embolization is in most cases the first line of treatment but does not always achieve cure. Gamma Knife (GK) radiosurgery represents an alternative treatment option, and the purpose of this study was to further evaluate its utility. Methods We reviewed all cases of DAVF treated between 2009 and 2016 at our institution with GK radiosurgery independently, or following failed/refused endovascular or surgical management. Patients' clinical files, radiological images, catheter angiograms, and surgical DAVF disconnection reports were retrospectively reviewed. Results Sixteen DAVF (14 patients) treated by GK radiosurgery were identified. Eleven fistulae were aggressive and five were benign. Marginal doses ranged from 15 to 25 Gy. Target volumes ranged from 0.04 to 4.47 cm3. In all symptomatic patients, GK treatment resulted in symptom palliation. In 13/15 lesions, cure of symptoms (86.0%) was reported. One lesion was asymptomatic. Angiographic cure was achieved in eight cases (50%), small residual DAVF occurred in four, and four were unchanged. One patient developed headache that resolved at one year. No hemorrhage occurred during the follow-up period. There was no significant association between Borden type and cure rate. Prior failed endovascular treatment and small target volume were associated with lower rates of cure. Conclusions Stereotactic radiosurgery is viable treatment for DAVF. It is very effective in palliating symptoms as a de novo approach or adjunctive to endovascular therapy. In our experience it is only somewhat effective in achieving complete angiographic cure.
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Affiliation(s)
- Adam A Dmytriw
- 1 Department of Medical Imaging, Division of Neuroradiology, Toronto Western Hospital, University Health Network & University of Toronto, Canada
| | - Michael L Schwartz
- 2 Department of Neurosurgery, Sunnybrook Health Sciences Centre and Gamma Knife Centre, Toronto Western Hospital, Canada
| | | | - Vitor Mendes Pereira
- 1 Department of Medical Imaging, Division of Neuroradiology, Toronto Western Hospital, University Health Network & University of Toronto, Canada
| | - Timo Krings
- 1 Department of Medical Imaging, Division of Neuroradiology, Toronto Western Hospital, University Health Network & University of Toronto, Canada
| | - Michael Tymianski
- 4 Department of Neurosurgery, Toronto Western Hospital, University Health Network, Canada
| | - Ivan Radovanovic
- 4 Department of Neurosurgery, Toronto Western Hospital, University Health Network, Canada
| | - Ronit Agid
- 1 Department of Medical Imaging, Division of Neuroradiology, Toronto Western Hospital, University Health Network & University of Toronto, Canada
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Abstract
Recent clinical data showing thermal lesions from treatments of essential tremor using MR-guided transcranial focused ultrasound shows that in many cases the focus is oblique to the main axis of the phased array. The potential for this obliquity to extend the focus into lateral regions of the brain has led to speculation as to the cause of the oblique focus, and whether it is possible to realign the focus. Numerical simulations were performed on clinical export data to analyze the causes of the oblique focus and determine methods for its correction. It was found that the focal obliquity could be replicated with the numerical simulations to within [Formula: see text] of the clinical cases. It was then found that a major cause of the focal obliquity was the presence of sidelobes, caused by an unequal deposition of power from the different transducer elements in the array at the focus. In addition, it was found that a 65% reduction in focal obliquity was possible using phase and amplitude corrections. Potential drawbacks include the higher levels of skull heating required when modifying the distribution of power among the transducer elements, and the difficulty at present in obtaining ideal phase corrections from CT information alone. These techniques for the reduction of focal obliquity can be applied to other applications of transcranial focused ultrasound involving lower total energy deposition, such as blood-brain barrier opening, where the issue of skull heating is minimal.
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Affiliation(s)
- Alec Hughes
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Yuexi Huang
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Aki Pulkkinen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Michael L Schwartz
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Canada
| | - Kullervo Hynynen
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
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