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Xiong Y, Han D, He J, Zong R, Bian X, Duan C, Zhang D, Zhou X, Pan L, Lou X. Correlation of visual area with tremor improvement after MRgFUS thalamotomy in Parkinson's disease. J Neurosurg 2021; 136:681-688. [PMID: 34479209 DOI: 10.3171/2021.3.jns204329] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE MRI-guided focused ultrasound (MRgFUS) thalamotomy is a novel and minimally invasive alternative for medication-refractory tremor in Parkinson's disease (PD). However, the impact of MRgFUS thalamotomy on spontaneous neuronal activity in PD remains unclear. The purpose of the current study was to evaluate the effects of MRgFUS thalamotomy on local fluctuations in neuronal activity as measured by the fractional amplitude of low-frequency fluctuations (fALFF) in patients with PD. METHODS Participants with PD undergoing MRgFUS thalamotomy were recruited. Tremor scores were assessed before and 3 and 12 months after treatment using the Clinical Rating Scale for Tremor. MRI data were collected before and 1 day, 1 week, 1 month, 3 months, and 12 months after thalamotomy. The fALFF was calculated. A whole-brain voxel-wise paired t-test was used to identify significant changes in fALFF at 12 months after treatment compared to baseline. Then fALFF in the regions with significant differences were extracted from fALFF maps of patients for further one-way repeated-measures ANOVA to investigate its dynamic alterations. The association between fALFF changes induced by thalamotomy and tremor improvement were evaluated using the nonparametric Spearman rank test. RESULTS Nine participants with PD (mean age ± SD 64.7 ± 6.1 years, 8 males) were evaluated. Voxel-based analysis showed that fALFF in the left occipital cortex (Brodmann area 17 [BA17]) significantly decreased at 12 months after thalamotomy compared to baseline (voxel p < 0.001, cluster p < 0.05 family-wise error [FWE] corrected). At baseline, fALFF in the left occipital BA17 in patients was elevated compared with that in 9 age- and gender-matched healthy subjects (p < 0.05). Longitudinal analysis displayed the dynamic changes of fALFF in this region (F (5,40) = 3.61, p = 0.009). There was a significant positive correlation between the falling trend in fALFF in the left occipital BA17 and hand tremor improvement after treatment over 3 time points (Spearman's rho = 0.44, p = 0.02). CONCLUSIONS The present study investigated the impact of MRgFUS ventral intermediate nucleus thalamotomy on spontaneous neural activity in medication-refractory tremor-dominant PD. The visual area is, for the first time, reported as relevant to tremor improvement in PD after MRgFUS thalamotomy, suggesting a distant effect of MRgFUS thalamotomy and the involvement of specific visuomotor networks in tremor control in PD.
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Affiliation(s)
- Yongqin Xiong
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Dongshan Han
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Jianfeng He
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Rui Zong
- 2Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China; and
| | - Xiangbing Bian
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Caohui Duan
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Dekang Zhang
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Xin Zhou
- 3Innovation Academy for Precision Measurement Science and Technology, The Chinese Academy of Sciences-Wuhan National Laboratory for Optoelectronics, Wuhan, China
| | - Longsheng Pan
- 2Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China; and
| | - Xin Lou
- 1Department of Radiology, Chinese PLA General Hospital, Beijing, China
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Eisenberg HM, Krishna V, Elias WJ, Cosgrove GR, Gandhi D, Aldrich CE, Fishman PS. MR-guided focused ultrasound pallidotomy for Parkinson's disease: safety and feasibility. J Neurosurg 2021; 135:792-798. [PMID: 33481557 DOI: 10.3171/2020.6.jns192773] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiofrequency pallidotomy has demonstrated improvement in motor fluctuations in patients with Parkinson's disease (PD), particularly levodopa (L-dopa)-induced dyskinesias. The authors aimed to determine whether or not unilateral pallidotomy with MR-guided focused ultrasound (MRgFUS) could safely improve Unified Dyskinesia Rating Scale (UDysRS; the primary outcome measure) scores over baseline scores in patients with PD. METHODS Twenty patients with PD and L-dopa responsiveness, asymmetrical motor signs, and motor fluctuations, including dyskinesias, participated in a 1-year multicenter open-label trial of unilateral MRgFUS ablation of the globus pallidus internus. RESULTS The sonication procedure was successfully completed in all 20 enrolled patients. MRgFUS-related adverse neurological events were generally mild and transient, including visual field deficit (n = 1), dysarthria (n = 4, 2 mild and 2 moderate), cognitive disturbance (n = 1), fine motor deficit (n = 2), and facial weakness (n = 1). Although 3 adverse events (AEs) were rated as severe (transient sonication-related pain in 2, nausea/vomiting in 1), no AE fulfilled US FDA criteria for a Serious Adverse Effect. Total UDysRS, the primary outcome measure, improved 59% after treatment (baseline mean score 36.1, 95% CI 4.88; at 3 months 14.2, 95% CI 5.72, p < 0.0001), which was sustained throughout the study (at 12 months 20.5, 95% CI 7.39, 43% improvement, p < 0.0001). The severity of motor signs on the treated side (Movement Disorder Society version of the United Parkinson's Disease Rating Scale [MDS-UPDRS] part III) in the "off" medication state also significantly improved (baseline mean score 20.0, 95% CI 2.4; at 3 months 10.6, 95% CI 1.86, 44.5% improvement, p < 0.0001; at 12 months 10.4, 95% CI 2.11, 45.2% improvement, p > 0.0001). The vast majority of patients showed a clinically meaningful level of improvement on the impairment component of the UDysRS or the motor component of the UPDRS, while 1 patient showed clinically meaningful worsening on the UPDRS at month 3. CONCLUSIONS This study supports the feasibility and preliminary efficacy of MRgFUS pallidotomy in the treatment of patients with PD and motor fluctuations, including dyskinesias. These preliminary data support continued investigation, and a placebo-controlled, blinded trial is in progress. Clinical trial registration no.: NCT02263885 (clinicaltrials.gov).
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Affiliation(s)
| | - Vibhor Krishna
- 2Department of Neurosurgery, Ohio State University Medical Center, Columbus, Ohio
| | - W Jeffrey Elias
- 3Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, Virginia; and
| | - G Rees Cosgrove
- 4Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Paul S Fishman
- 6Neurology, University of Maryland School of Medicine, Baltimore, Maryland
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Focused ultrasound for functional neurosurgery. J Neurooncol 2021; 156:17-22. [PMID: 34383232 DOI: 10.1007/s11060-021-03818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Brain lesioning is a fundamental technique in the functional neurosurgery world. It has been investigated for decades and presented promising results long before novel pharmacological agents were introduced to treat movement disorders, psychiatric disorders, pain, and epilepsy. Ablative procedures were replaced by effective drugs during the 1950s and by Deep Brain Stimulation (DBS) in the 1990s as a reversible neuromodulation technique. In the last decade, however, the popularity of brain lesioning has increased again with the introduction of magnetic resonance-guided focused ultrasound (MRgFUS). OBJECTIVE In this review, we will cover the current and emerging role of MRgFUS in functional neurosurgery. METHODS Literature review from PubMed and compilation. RESULTS Investigated since 1930, MRgFUS is a technology enabling targeted energy delivery at the convergence of mechanical sound waves. Based on technological advancements in phased array ultrasound transducers, algorithms accounting for skull penetration by sound waves, and MR imaging for targeting and thermometry, MRgFUS is capable of brain lesioning with sub-millimeter precision and can be used in a variety of clinical indications. CONCLUSION MRgFUS is a promising technology evolving as a dominant tool in different functional neurosurgery procedures in movement disorders, psychiatric disorders, epilepsy, among others.
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Kremer NI, Pauwels RWJ, Pozzi NG, Lange F, Roothans J, Volkmann J, Reich MM. Deep Brain Stimulation for Tremor: Update on Long-Term Outcomes, Target Considerations and Future Directions. J Clin Med 2021; 10:3468. [PMID: 34441763 PMCID: PMC8397098 DOI: 10.3390/jcm10163468] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023] Open
Abstract
Deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus is one of the main advanced neurosurgical treatments for drug-resistant tremor. However, not every patient may be eligible for this procedure. Nowadays, various other functional neurosurgical procedures are available. In particular cases, radiofrequency thalamotomy, focused ultrasound and radiosurgery are proven alternatives to DBS. Besides, other DBS targets, such as the posterior subthalamic area (PSA) or the dentato-rubro-thalamic tract (DRT), may be appraised as well. In this review, the clinical characteristics and pathophysiology of tremor syndromes, as well as long-term outcomes of DBS in different targets, will be summarized. The effectiveness and safety of lesioning procedures will be discussed, and an evidence-based clinical treatment approach for patients with drug-resistant tremor will be presented. Lastly, the future directions in the treatment of severe tremor syndromes will be elaborated.
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Affiliation(s)
- Naomi I. Kremer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Rik W. J. Pauwels
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
| | - Nicolò G. Pozzi
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Florian Lange
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Martin M. Reich
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
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Chen X, Wang D, Zhang L, Yao H, Zhu H, Zhao N, Peng X, Yang K. Neuroprotective Effect of Low-Intensity Pulsed Ultrasound on the Mouse MPTP/MPP + Model of Dopaminergic Neuron Injury. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2321-2330. [PMID: 34011450 DOI: 10.1016/j.ultrasmedbio.2021.03.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 06/12/2023]
Abstract
Ultrasound mediated neuromodulation has been demonstrated to a safe treatment strategy in the field of neuroscience. In this study, low-intensity pulsed ultrasound (LIPUS) was used to treat Parkinson's disease (PD) models induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and 1-methyl-4-phenylpyridinium (MPP+) to explore the possibility of ultrasound neuroprotective effect on PD. The results demonstrated that LIPUS treatment can attenuate the central neurotoxicity of MPTP in mice, reduce the loss of tyrosine hydroxylase positive neurons in the substantia nigra pars compacta and decrease the apoptosis in the section of substantia nigra. The movement and balance dysfunctions in PD mice were improved with LIPUS treatment. In addition, we demonstrated that LIPUS can inhibit the decreased activity and increased apoptosis of dopaminergic neurons induced by MPP+, restrain the accumulation of reactive oxygen species (ROS) and decrease of mitochondrial membrane potential caused by MPP+. Moreover, LIPUS stimulation alone did not cause any cytotoxicity and tissue damage in our study. Taken together, the protective and regulatory effects of LIPUS on dopaminergic neurons make it possible as a new, safe and noninvasive treatment for PD.
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Affiliation(s)
- Xueying Chen
- Pediatric Research Institute, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China; Department of Ultrasound, the First Affiliated Hospital of Chongqing Medical University Chongqing, China
| | - Dong Wang
- Department of Ultrasound, the First Affiliated Hospital of Chongqing Medical University Chongqing, China; Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing Medical University, Chongqing, PR, China
| | - Liang Zhang
- Department of Ultrasound, the First Affiliated Hospital of Chongqing Medical University Chongqing, China; Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing Medical University, Chongqing, PR, China
| | - Huan Yao
- Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing Medical University, Chongqing, PR, China
| | - Hui Zhu
- Department of Ultrasound, the First Affiliated Hospital of Chongqing Medical University Chongqing, China
| | - Nvjun Zhao
- Department of Ultrasound, the First Affiliated Hospital of Chongqing Medical University Chongqing, China
| | - Xiaoqiong Peng
- Department of Ultrasound, the First Affiliated Hospital of Chongqing Medical University Chongqing, China
| | - Ke Yang
- Pediatric Research Institute, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China.
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YAMAMOTO K, ITO H, FUKUTAKE S, ODO T, KAMEI T, YAMAGUCHI T, TAIRA T. Focused Ultrasound Thalamotomy for Tremor-dominant Parkinson's Disease: A Prospective 1-year Follow-up Study. Neurol Med Chir (Tokyo) 2021; 61:414-421. [PMID: 33967176 PMCID: PMC8280323 DOI: 10.2176/nmc.oa.2020-0370] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/08/2021] [Indexed: 11/23/2022] Open
Abstract
Transcranial magnetic resonance (MR)-guided focused ultrasound (FUS) therapy is an emerging and minimally invasive treatment for movement disorders. There are limited reports on its long-term outcomes for tremor-dominant Parkinson's disease (TDPD). We aimed to investigate the 1-year outcomes of ventralis intermedius (VIM) thalamotomy with FUS in patients with TDPD. Patients with medication-refractory TDPD were enrolled and underwent unilateral VIM-FUS thalamotomy. Neurologists specializing in movement disorders evaluated the tremor symptoms and disability using Parts A, B, and C of the Clinical Rating Scale for Tremor (CRST) at baseline and at 1, 3, and 12 months. In all, 11 patients (mean age: 71.6 years) were included in the analysis. Of these, five were men. The median (interquartile range) improvement from baseline in hand tremor score, the total score, and functional disability score were 87.9% (70.5-100.0), 65.3% (55.7-87.7), and 66.7% (15.5-85.1), respectively, at 12 months postoperatively. This prospective study demonstrated an improvement in the tremor and disability of patients at 12 months after unilateral VIM-FUS thalamotomy for TDPD. In addition, there were no serious persistent adverse events. Our results indicate that VIM-FUS thalamotomy can be safely and effectively used to treat patients with TDPD. A randomized controlled trial with a larger cohort and long blinded period would help investigate the recurrence, adverse effects, placebo effects, and longer efficacy of this technique.
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Affiliation(s)
- Kazuaki YAMAMOTO
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Neurosurgery, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Hisashi ITO
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Shigeru FUKUTAKE
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Takashi ODO
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Tetsumasa KAMEI
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Toshio YAMAGUCHI
- Research Institute of Diagnostic Imaging, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Takaomi TAIRA
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
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Ge Y, Wang Z, Gu F, Yang X, Chen Z, Dong W, Wang Z. Clinical application of magnetic resonance-guided focused ultrasound in Parkinson's disease: a meta-analysis of randomized clinical trials. Neurol Sci 2021; 42:3595-3604. [PMID: 34216307 DOI: 10.1007/s10072-021-05443-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND To evaluate the safety and efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) in the treatment of Parkinson's disease (PD). METHODS The databases of Medline, EMBASE, and the Cochrane Library were searched for eligible randomized controlled trials comparing focused ultrasound surgery (FUS) group vs. sham procedure group in PD. Weighted mean differences and standardized mean differences with corresponding 95% confidence intervals were used to summarize the primary outcome, namely, the effect of MRgFUS to improve limb tremor in PD patients and adverse events, and the secondary outcome, which is the effect of MRgFUS in improving the quality of life, activities of daily living, and non-motor symptoms. RESULTS The pooled analysis comprised 2 studies. The blinded phase lasted for 4 months in one experiment and up to 3 months in the other. The FUS group showed significant improvement in limb tremor on the treated side (SMD: - 1.20; 95% CI: - 2.06, - 0.34) and the ability to perform daily activities (SMD: - 0.86; 95% CI: - 1.41, - 0.32) compared to the sham group, but there were no significant group differences in other indicators. Of the process-related adverse events, dizziness (OR: 4.68; 95% CI: 1.20, 18.23) was more common in the treatment group, with no group differences in the remaining adverse events. CONCLUSIONS These findings suggest beneficial effects of MRgFUS in PD patients with no serious side effects. Larger multicenter studies are needed in the future to select the most appropriate target and surgical device setup parameters.
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Affiliation(s)
- Yi Ge
- Department of Neurology, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Zilan Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Feng Gu
- First Clinical Medical School, Soochow University, Suzhou, 215006, Jiangsu Province, China
| | - Xingyu Yang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Wanli Dong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China.
- Department of Neurology, Dushuhu Public Hospital Affiliated To Soochow University, Jiangsu Province, Suzhou, 215006, China.
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
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Valentino F, Cosentino G, Maugeri R, Giammalva R, Iacopino GD, Marrale M, Bartolotta TV, Gagliardo C. Is Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound a Repeatable Treatment Option? Case Report of a Retreated Patient With Tremor Combined With Parkinsonism. Oper Neurosurg (Hagerstown) 2021; 18:577-582. [PMID: 31598711 DOI: 10.1093/ons/opz300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 07/29/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In recent years, transcranial Magnetic Resonance Imaging-guided Focused Ultrasound (tcMRgFUS) treatments for functional neurological disorders are giving a new thrust to the field of therapeutic brain lesioning. OBJECTIVE To present the case of a patient affected by tremor combined with Parkinsonism who underwent a second tcMRgFUS thalamotomy because of relapsing tremor after a few months from the first tcMRgFUS treatment. METHODS A 72-yr-old, right-handed man, came to our observation because of a disabling tremor affecting his upper limbs, refusing any invasive surgical procedure and already treated by tcMRgFUS left Vim thalamotomy. However, clinical benefit had brief duration, as a progressive recurrence of tremor on the right upper limb was observed after a few months from the first treatment. Thus, the patient underwent a new left-sided tcMRgFUS procedure 6 mo after the former treatment. RESULTS After the second procedure, an immediate and complete relief from tremor on the right upper limb was achieved with clinical benefit that persisted up to a 6-mo follow-up. CONCLUSION Since tcMRgFUS doesn't use ionizing radiations and it is incision-less, repeated and staged treatment procedures have always been hypothesized. Our report suggests that tcMRgFUS retreatment might actually be a feasible, safe, and effective option in selected patients in whom an optimal clinical outcome is not achieved after the first treatment session. However, future well-designed studies in large samples are needed to assess the possible risks of retreatment and the optimal timing of reintervention as well as eligibility and exclusion criteria.
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Affiliation(s)
- Francesca Valentino
- Neurology Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giuseppe Cosentino
- Neurology Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy.,Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy.,Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Italy, IRCCS Mondino Foundation, Pavia, Italy
| | - Rosario Maugeri
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy
| | - Roberto Giammalva
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy
| | - Gerardo Domenico Iacopino
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy
| | - Maurizio Marrale
- Department of Physics and Chemistry, University of Palermo, Palermo, Italy
| | - Tommaso Vincenzo Bartolotta
- Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Cesare Gagliardo
- Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy
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Solomon O, Palnitkar T, Patriat R, Braun H, Aman J, Park MC, Vitek J, Sapiro G, Harel N. Deep-learning based fully automatic segmentation of the globus pallidus interna and externa using ultra-high 7 Tesla MRI. Hum Brain Mapp 2021; 42:2862-2879. [PMID: 33738898 PMCID: PMC8127160 DOI: 10.1002/hbm.25409] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/16/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022] Open
Abstract
Deep brain stimulation (DBS) surgery has been shown to dramatically improve the quality of life for patients with various motor dysfunctions, such as those afflicted with Parkinson's disease (PD), dystonia, and essential tremor (ET), by relieving motor symptoms associated with such pathologies. The success of DBS procedures is directly related to the proper placement of the electrodes, which requires the ability to accurately detect and identify relevant target structures within the subcortical basal ganglia region. In particular, accurate and reliable segmentation of the globus pallidus (GP) interna is of great interest for DBS surgery for PD and dystonia. In this study, we present a deep-learning based neural network, which we term GP-net, for the automatic segmentation of both the external and internal segments of the globus pallidus. High resolution 7 Tesla images from 101 subjects were used in this study; GP-net is trained on a cohort of 58 subjects, containing patients with movement disorders as well as healthy control subjects. GP-net performs 3D inference in a patient-specific manner, alleviating the need for atlas-based segmentation. GP-net was extensively validated, both quantitatively and qualitatively over 43 test subjects including patients with movement disorders and healthy control and is shown to consistently produce improved segmentation results compared with state-of-the-art atlas-based segmentations. We also demonstrate a postoperative lead location assessment with respect to a segmented globus pallidus obtained by GP-net.
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Affiliation(s)
- Oren Solomon
- Department of Radiology, Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Tara Palnitkar
- Department of Radiology, Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Re'mi Patriat
- Department of Radiology, Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Henry Braun
- Department of Radiology, Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Joshua Aman
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Michael C. Park
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesotaUSA
- Department of NeurosurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Jerrold Vitek
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Guillermo Sapiro
- Department of Electrical and Computer EngineeringDuke UniversityDurhamNorth CarolinaUSA
- Department of Biomedical EngineeringDuke UniversityDurhamNorth CarolinaUSA
- Department of Computer ScienceDuke UniversityDurhamNorth CarolinaUSA
- Department of MathematicsDuke UniversityDurhamNorth CarolinaUSA
| | - Noam Harel
- Department of Radiology, Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
- Department of NeurosurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
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Horisawa S, Yamaguchi T, Abe K, Hori H, Fukui A, Iijima M, Sumi M, Hodotsuka K, Konishi Y, Kawamata T, Taira T. Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Focal Hand Dystonia: A Pilot Study. Mov Disord 2021; 36:1955-1959. [PMID: 34050695 PMCID: PMC8453941 DOI: 10.1002/mds.28613] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/06/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background The efficacy of magnetic resonance‐guided focused ultrasound (MRgFUS) thalamotomy for the treatment of focal hand dystonia (FHD) is not well known. Objective We aimed to prospectively investigate the efficacy of MRgFUS thalamotomy for the treatment of FHD. Methods We performed MRgFUS thalamotomy of the ventro‐oral (Vo) nucleus in 10 patients with FHD. We evaluated the scores of the Writer's Cramp Rating Scale (WCRS, 0–30; higher scores indicating greater severity), Tubiana Musician's Dystonia Scale (TMDS, 0–5; lower scores indicating greater severity), and Arm Dystonia Disability Scale (ADDS, 0%–100%; lower scores indicating greater disability) at baseline and 3 and 12 months post‐treatment. Results WCRS, TMDS, and ADDS scores significantly improved from 6.3 ± 2.7, 1.4 ± 0.5, and 58.7% ± 14.3% at baseline to 1.6 ± 3.1 (P = 0.011), 5.0 ± 0 (P = 0.0001), and 81.6% ± 22.9% (P = 0.0229) at 12 months, respectively. There was one prolonged case of dysarthria at 12 months. Conclusion We show that MRgFUS Vo‐thalamotomy significantly improved FHD. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Shiro Horisawa
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Yamaguchi
- Department of Radiology, Shinyurigaoka General Hospital, Kanagawa, Japan
| | - Keiichi Abe
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroki Hori
- Department of Radiology, Shinyurigaoka General Hospital, Kanagawa, Japan
| | - Atsushi Fukui
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Mutsumi Iijima
- Department of Neurology, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Masatake Sumi
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Kenichi Hodotsuka
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshiyuki Konishi
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering & Science, Graduate School of Medicine, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
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Magnetic resonance-guided focused ultrasound treatment for essential tremor shows sustained efficacy: a meta-analysis. Neurosurg Rev 2021; 45:533-544. [PMID: 33978922 DOI: 10.1007/s10143-021-01562-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/12/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Although magnetic resonance-guided focused ultrasound (MRgFUS) is a viable treatment option for essential tremor, some studies note a diminished treatment benefit over time. A PubMed search was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if hand tremor scores (HTS), total Clinical Rating Scale for Tremor (CRST) scores, or Quality of Life in Essential Tremor Questionnaire (QUEST) scores at regular intervals following MRgFUS treatment for essential tremor were documented. Data analyses included a random effects model of meta-analysis and mixed-effects model of meta-regression. Twenty-one articles reporting HTS for 395 patients were included. Mean pre-operative HTS was 19.2 ± 5.0. Mean HTS at 3 months post-treatment was 7.4 ± 5.0 (61.5% improvement, p < 0.001). Treatment effect was mildly decreased at 36 months at 9.1 ± 5.4 (8.8% reduction). Meta-regression of time since treatment as a modifier of HTS revealed a downward trend in effect size, though this was not statistically significant (p = 0.208). Only 4 studies included follow-up ≥ 24 months. Thirteen included articles reported total CRST scores with standardized follow-up for 250 patients. Mean pre-operative total CRST score decreased by 46.2% at 3 months post-treatment (p < 0.001). Additionally, mean QUEST scores at 3 months post-treatment significantly improved compared to baseline (p < 0.001). HTS is significantly improved from baseline ≥ 24 months post-treatment and possibly ≥ 48 months post-treatment. There is a current paucity of long-term CRST and QUEST score reporting in the literature.
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Abe K, Horisawa S, Yamaguchi T, Hori H, Yamada K, Kondo K, Furukawa H, Kamada H, Kishima H, Oshino S, Mochizuki H, Kanemoto M, Hirabayashi H, Fukutome K, Ohnishi H, Igase K, Matsubara I, Ohnishi T, Sadamoto K, Taira T. Focused Ultrasound Thalamotomy for Refractory Essential Tremor: A Japanese Multicenter Single-Arm Study. Neurosurgery 2021; 88:751-757. [PMID: 33469648 DOI: 10.1093/neuros/nyaa536] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/10/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Several feasibility studies and a randomized, controlled, multicenter trial have demonstrated the safety and efficacy of unilateral transcranial magnetic resonance-guided focused ultrasound (FUS) lesioning of the ventral intermediate thalamic nucleus in treating essential tremor. OBJECTIVE To evaluate the safety and efficacy of FUS thalamotomy in a Japanese patient cohort through a prospective, multicenter, single-arm confirmatory trial. METHODS A total of 35 patients with disabling refractory essential tremor underwent unilateral FUS thalamotomy and were followed up for 12 post-treatment months. Safety was measured as the incidence and severity of treatment-related adverse events. Efficacy was measured as the tremor severity and quality of life improvements using the Clinical Rating Scale for Tremor and Questionnaire for Essential Tremor. RESULTS The mean skull density ratio (SDR) was 0.47. There was a significant decrease in the mean postural tremor score of the treated hand from baseline to 12 mo by 56.4% (95% CI: 46.7%-66.1%; P < .001), which was maintained at last follow-up. Quality of life improved by 46.3% (mean overall Questionnaire for Essential Tremor score of 17.4 [95% CI: 12.1-22.7]) and there were no severe adverse events. The most frequent adverse event was gait disturbance and all events resolved. CONCLUSION Unilateral FUS thalamotomy allowed significant and sustained tremor relief and improved the quality of life with an outstanding safety profile. The observed safety and efficacy of FUS thalamotomy were comparable to those reported in a previous multicenter study with a low SDR, and inclusion of the low SDR group did not affect effectiveness.
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Affiliation(s)
- Keiichi Abe
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shiro Horisawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Hiroki Hori
- Shinyurigaoka General Hospital, Kanagawa, Japan
| | - Kazumichi Yamada
- Division of Speech-Language-Hearing Therapy, Department of Rehabilitation, Faculty of Health Science, Kumamoto Health Science University, Chuo-ku, Japan
| | - Kimito Kondo
- Department of Neurology, Hokuto Hospital, Obihiro, Japan
| | | | - Hajime Kamada
- Department of Neurology, Hokuto Hospital, Obihiro, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoru Oshino
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Hidehiro Hirabayashi
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Kenji Fukutome
- Department of Neurosurgery, Ohnishi Neurological Center, Hyogo, Japan
| | - Hideyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Hyogo, Japan
| | - Keiji Igase
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Ichiro Matsubara
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Takanori Ohnishi
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Kazuhiko Sadamoto
- Department of Neurosurgery, Washokai Sadamoto Hospital, Ehime, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Agrawal M, Garg K, Samala R, Rajan R, Naik V, Singh M. Outcome and Complications of MR Guided Focused Ultrasound for Essential Tremor: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:654711. [PMID: 34025558 PMCID: PMC8137896 DOI: 10.3389/fneur.2021.654711] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Magnetic resonance guided focused ultrasound (MRgFUS) is a relatively novel technique to treat essential tremor (ET). The objective of this review was to analyze the efficacy and the safety profile of MRgFUS for ET. Methods: A systematic literature review was done. The post procedure changes in the Clinical Rating Scale for Tremor (CRST) score, hand score, disability and quality of life scores were analyzed. Results: We found 29 studies evaluating 617 patients. DTI based targeting was utilized in six cohorts. A significant difference was observed in the pooled standard mean difference between the pre and postoperative total CRST score (p-value < 0.001 and 0.0002), hand score (p-value 0.03 and 0.02); and the disability at 12 months (p-value 0.01). Head pain and dizziness were the most in procedure complications. The immediate pooled proportion of ataxia was 50%, while it was 20% for sensory complications, which, respectively, declined to 31 and 13% on long term follow up. A significant reduction (p = 0.03) in immediate ataxia related complications was seen with DTI targeting. Conclusion: MRgFUS for ET seems to be an effective procedure for relieving unilateral tremor. Use of DTI based targeting revealed a significant reduction in post procedure ataxia related complications as compared to traditional targeting techniques. Analysis of other complications further revealed a decreasing trend on follow up.
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Affiliation(s)
- Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Roopa Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Naik
- Department of Neurosurgery, Bangalore Medical College, Bangalore, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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64
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Iorio-Morin C, Hodaie M, Lozano AM. Adoption of focused ultrasound thalamotomy for essential tremor: why so much fuss about FUS? J Neurol Neurosurg Psychiatry 2021; 92:549-554. [PMID: 33563810 DOI: 10.1136/jnnp-2020-324061] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 11/27/2020] [Accepted: 12/22/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Focused ultrasound (FUS) was approved as a new treatment modality for essential tremor (ET) in 2016. The goal of this study was to quantify FUS adoption for ET and understand its drivers. METHODS The adoption of the various surgical options for ET was estimated using three measures: the number of presentations on the various surgical treatments for ET at specialised international meetings, the number of original papers published as identified by literature searches and the number of thalamotomy procedures performed worldwide for ET as provided by device manufacturers' registries. RESULTS First, we found that the number of presentations related to lesioning procedures is increasing relative to deep brain stimulation (DBS) at international meetings. Second, there are already more publications on FUS (93) than stereotactic radiosurgery (SRS) (68) or radiofrequency (43) for ET, although they still lag behind DBS papers (750). Third, the number of annual FUS thalamotomies performed for ET (n>1200 in 2019) in 44 centres has surpassed the annual procedures across 342 Gamma Knife units (n<400, 2018) but is yet to reach the number of DBS cases for ET estimated at over 2400/year. CONCLUSION FUS is being rapidly adopted for the treatment of ET. We hypothesise that its perceived minimally invasive nature coupled with the ability to perform intraoperative clinical assessments, its immediate effects and active marketing efforts are contributing factors. As lesioning modalities for the treatment of ET are reappraised, the superior popularity of FUS over SRS appears to arise for reasons other than differences in clinical outcomes.
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Affiliation(s)
- Christian Iorio-Morin
- Neurosurgery, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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65
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Cacho-Asenjo E, Honorato-Cia C, Nuñez-Cordoba JM, Fernandez-Martinez M, Gonzalez-Quarante LH, Aviles-Olmos I, Gorospe MA, Panadero A, Rodríguez-Oroz MC, Guridi J, Martinez-Simon A. Factors Associated with Headache and Nausea During Magnetic Resonance-Guided Focused Ultrasound for Tremor. Mov Disord Clin Pract 2021; 8:701-708. [PMID: 34307742 DOI: 10.1002/mdc3.13210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/07/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background During magnetic resonance-guided focused ultrasound for essential or parkinsonian tremor, adverse events (headache, nausea/vomiting, or anxiety) may alter the outcome of the procedure despite being mostly transient and mild. Objectives Our aim was to analyze the relationship between demographic, procedural, and anesthetic characteristics with magnetic resonance/ultrasound-related events. Methods This was a retrospective study at the Clinica Universidad de Navarra of patients undergoing thalamotomy with magnetic resonance-guided focused ultrasound between September 2018 and October 2019. The anesthesia protocol included headache and nausea/vomiting prophylaxis and rescue therapy. Dexmedetomidine was used for anxiolysis in some patients after thorough multidisciplinary assessment. Results A total of 123 patients were included. Headache was directly related to skull density ratio (P < 0.001) and skull thickness (P = 0.02). Patients with a skull density ratio less than 0.48 had 3 times the odds of experiencing moderate or severe headache (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.21-7.82) and had a higher odds of aborting sonication due to pain. Sex was associated with increased nausea (P = 0.007). Women had 4 times the odds of nausea than men (OR, 4.4; 95% CI, 1.61-12.11). Dexmedetomidine did not reduce headache or nausea incidence. Patients who received dexmedetomidine had a higher number (P = 0.01) and total minutes of sonication (P = 0.01). Conclusions Patients with lower skull density ratios and higher skull thicknesses could benefit from an aggressive analgesic prophylaxis. Women are more likely to experience nausea. Dexmedetomidine did not reduce headache and nausea, but increased the number and duration of sonications. Its exact effect on tremor is still unclear.
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Affiliation(s)
- Elena Cacho-Asenjo
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain.,Instituto de Investigación Sanitaria de Navarra Pamplona Spain
| | - Cristina Honorato-Cia
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain.,Instituto de Investigación Sanitaria de Navarra Pamplona Spain
| | - Jorge M Nuñez-Cordoba
- Research Support Service, Central Clinical Trials Unit Clinica Universidad de Navarra Pamplona Spain
| | | | | | | | | | - Alfredo Panadero
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain
| | | | - Jorge Guridi
- Department of Neurosurgery Clinica Universidad de Navarra Pamplona Spain
| | - Antonio Martinez-Simon
- Department of Anesthesiology and Critical Care Clinica Universidad de Navarra Pamplona Spain.,Instituto de Investigación Sanitaria de Navarra Pamplona Spain
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Ntetsika T, Papathoma PE, Markaki I. Novel targeted therapies for Parkinson's disease. Mol Med 2021; 27:17. [PMID: 33632120 PMCID: PMC7905684 DOI: 10.1186/s10020-021-00279-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
Parkinson’s disease (PD) is the second more common neurodegenerative disease with increasing incidence worldwide associated to the population ageing. Despite increasing awareness and significant research advancements, treatment options comprise dopamine repleting, symptomatic therapies that have significantly increased quality of life and life expectancy, but no therapies that halt or reverse disease progression, which remain a great, unmet goal in PD research. Large biomarker development programs are undertaken to identify disease signatures that will improve patient selection and outcome measures in clinical trials. In this review, we summarize PD-related mechanisms that can serve as targets of therapeutic interventions aiming to slow or modify disease progression, as well as previous and ongoing clinical trials in each field, and discuss future perspectives.
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Affiliation(s)
- Theodora Ntetsika
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Center of Neurology, Academic Specialist Center, Solnavägen 1E, 113 65, Stockholm, Sweden
| | - Paraskevi-Evita Papathoma
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Danderyd Hospital Stockholm, Stockholm, Sweden
| | - Ioanna Markaki
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. .,Center of Neurology, Academic Specialist Center, Solnavägen 1E, 113 65, Stockholm, Sweden.
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67
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Gallay MN, Moser D, Jeanmonod D. MR-guided focused ultrasound cerebellothalamic tractotomy for chronic therapy-resistant essential tremor: anatomical target reappraisal and clinical results. J Neurosurg 2021; 134:376-385. [PMID: 32032945 DOI: 10.3171/2019.12.jns192219] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In addition to the well-recognized ventral intermediate nucleus (Vim) thalamotomy for the treatment of chronic therapy-resistant essential tremor (ET), an alternative approach targeting the posterior part of the subthalamus was proposed in the 1960s and early 1970s and then was reactualized as cerebellothalamic tractotomy (CTT) with the advent of MR-guided focused ultrasound (MRgFUS) surgery. The goal of this study was to improve target coverage and thus efficacy (i.e., tremor control and its consistency). The authors undertook a histological reappraisal of the CTT target and proposed a targeting strategy of the MRgFUS CTT based on 1) the MR visualization of the center of the red nucleus and 2) the application of preplanned target subunits realized with short sonications under thermal dose control. This study was aimed at demonstrating the efficacy and risk profile of this approach against chronic therapy-resistant ET. METHODS Ten consecutive patients suffering from chronic therapy-resistant ET benefited from a unilateral MRgFUS CTT and were followed over the course of 1 year. Primary endpoints were subjective tremor relief, Clinical Rating Scale for Tremor (CRST) score, activities of daily living (ADL) score, and the hand function (HF) scores HF16 and HF32. Histological reappraisal of the target led the authors to propose a standardized targeting protocol for MRgFUS CTT. Thermal doses for 18 and 240 cumulative equivalent minutes at 43°C were calculated and correlated with intraoperative and 2 days postoperative T2-weighted MR images. RESULTS The mean ± SD for the baseline CRST score was 48 ± 12; the score was 16 ± 7 at 3 months, and 17 ± 8 at 1 year. The mean tremor relief rated by the patients for the operated side was 95% after 2 days, 96% at 3 months, and 93% at 1 year. The mean HF16 was 11.0 ± 2.1 at baseline, 0.7 ± 0.7 at 3 months, and 0.8 ± 0.9 at 1 year (93% mean reduction). The minimum reduction for the HF16 at 1 year was 78%. There was a 51% reduction of the mean ADL score at 1 year. There was no bleeding or infection. Gait difficulties, only detectable on tandem gait, were increased in 3 patients and reduced in 2 patients at 1 year. There was no dysarthria. CONCLUSIONS The authors' results suggest that MRgFUS CTT is a very effective treatment option for therapy-resistant ET.
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Qu X, Shen G, Wu N, Wu H, Qiao S, Wang E, Chen Y, Wang H. Suppressing Grating Lobes for Transcranial Focused Ultrasound System by Frequency-Modulated Excitation. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2021; 68:341-351. [PMID: 33382650 DOI: 10.1109/tuffc.2020.3047664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Transcranial focused ultrasound is a novel noninvasive therapeutic modality for glioblastoma and other disorders of the brain. However, because the phase aberrations caused by the skull need to be corrected with computed tomography (CT) images, the transcranial transducer is tightly fixed on the patient's head to avoid any variation in the relative position, and the focus shifting relies mainly on the capacity for electronic beam steering. Due to the presence of grating lobes and the rapid degradation of the focus quality with increasing focus-shifting distance, transcranial focus-shifting sonication may damage healthy brain tissue unintentionally. To reduce the risks associated with transcranial focused ultrasound therapy, linear frequency-modulated (FM) excitation is proposed. The k-space corrected pseudospectral time domain (PSTD) and acoustic holography approach based on the Rayleigh integral are combined to calculate the distribution of the deposited acoustic power. The corresponding simulation was performed with axial/lateral focus shifting at different distances. The distributions of the deposited acoustic power show that linear FM excitation can effectively suppress undesired prefocal grating lobes without compromising focus quality.
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69
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Aresteanu RNS, Borodetsky A, Azhari H, Weitz IS. Ultrasound-induced and MRI-monitored CuO nanoparticles release from micelle encapsulation. NANOTECHNOLOGY 2021; 32:055705. [PMID: 33059339 DOI: 10.1088/1361-6528/abc1a1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Copper oxide nanoparticles (CuO NPs) have anticancer and antimicrobial activities. Moreover, they have a contrast enhancing effect in both MRI and ultrasound. Nonetheless, encapsulation is needed to control their toxic side effects and a mechanism for release on demand is required. A methodology is introduced herein for encapsulating and releasing CuO NPs from micelles by ultrasound induced hyperthermia and monitoring the process by MRI. For this aim, CuO NPs loaded poly(ethylene glycol)-block-poly(D,L-lactic acid) (PEG-b-PLA) micelles were prepared. Then, the profile of copper release with application of ultrasound was examined as a function of time and temperature using a colorimetric method. Finally, T1 weighted MRI images of suspensions and ex vivo poultry liver samples containing the CuO NPs loaded micelles were acquired before and after ultrasound application. The results confirmed that: (i) encapsulated NPs are detectible by MRI T1 mapping, depicting substantial T1 shortening from 1872 ± 62 ms to 683 ± 20 ms. (ii) Ultrasonic hyperthermia stimulated the NPs release with an about threefold increase compared to non-treated samples. (iii) Releasing effect was clearly visible by T1-weighted imaging (mean signal increase ratio of 2.29). These findings can potentially lead to the development of a new noninvasive methodology for CuO NPs based theranostic process.
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Affiliation(s)
| | | | - Haim Azhari
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Israel
| | - Iris S Weitz
- Department of Biotechnology Engineering, ORT Braude College, Israel
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Lin F, Wu D, Yu J, Weng H, Chen L, Meng F, Chen Y, Ye Q, Cai G. Comparison of efficacy of deep brain stimulation and focused ultrasound in parkinsonian tremor: a systematic review and network meta-analysis. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-323656. [PMID: 33461975 DOI: 10.1136/jnnp-2020-323656] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/25/2020] [Accepted: 12/22/2020] [Indexed: 02/07/2023]
Abstract
To compare the efficacy of deep brain stimulation (DBS) and MRI-guided focused ultrasound (MRIgFUS) in parkinsonian tremor. We performed a network meta-analysis based on a Bayesian framework. We searched the literature for articles published between January 1990 and October 2020 using three databases: PubMed, Embase and Cochrane Library (The Cochrane Database of Systematic Reviews). A total of 24 studies were included in our analysis, comprising data from 784 participants. Our findings revealed similar efficacy of DBS and MRIgFUS in parkinsonian tremor suppression. Compared with internal globus pallidus (GPi)-MRIgFUS, GPi-DBS -1.84 (-6.44, 2.86), pedunculopontine nucleus (PPN)_DBS -3.28 (-9.28, 2.78), PPN and caudal zona incerta (cZI)-DBS 0.40 (-6.16, 6.87), subthalamic nucleus (STN)_DBS 0.89 (-3.48, 5.30), STN and cZI-DBS 1.99 (-4.74, 8.65), ventral intermediate nucleus(VIM)_DBS 1.75 (-2.87, 6.48), VIM_FUS 0.72 (-5.27, 6.43), cZI-DBS 0.27 (-4.75, 5.36) were no significantly difference. Compared with VIM-MRIgFUS, GPi-DBS -2.55(-6.94, 2.21), GPi-FUS -0.72 (-6.43, 5.27), PPN_DBS -4.01(-9.97, 2.11), PPN and cZI-DBS -0.32 (-6.73, 6.36), STN_DBS 0.16 (-3.98, 4.6), STN and cZI-DBS 1.31(-5.18,7.87), VIM-DBS 1.00(-3.41, 5.84)and cZI-DBS -0.43 (-5.07, 4.68) were no significantly difference. With respect to the results for the treatment of motor symptoms, GPi-DBS, GPi-MRIgFUS, STN-DBS and cZI-DBS were significantly more efficacious than baseline (GPi-DBS 15.24 (5.79, 24.82), GPi-MRIgFUS 13.46 (2.46, 25.10), STN-DBS 19.62 (12.19, 27.16), cZI-DBS 14.18 (1.73, 26.89). The results from the surface under the cumulative ranking results showed that STN-DBS ranked first, followed by combined PPN and cZI-DBS, and PPN-DBS ranked last. MRIgFUS, an efficacious intervention for improving parkinsonian tremor, has not demonstrated to be inferior to DBS in parkinsonian tremor suppression. Hence, clinicians should distinguish individual patients' symptoms to ensure that the appropriate intervention and therapeutic approach are applied.
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Affiliation(s)
- Fabin Lin
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Department of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Dihang Wu
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Department of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Jiao Yu
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Huidan Weng
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Lina Chen
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Fangang Meng
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Chen
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Qinyong Ye
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Guoen Cai
- Department of Neurology, Union Hospital, Fujian Medical University, Fuzhou, China
- Institute or Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Department of Clinical Medicine, Fujian Medical University, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
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Marino BLB, de Souza LR, Sousa KPA, Ferreira JV, Padilha EC, da Silva CHTP, Taft CA, Hage-Melim LIS. Parkinson's Disease: A Review from Pathophysiology to Treatment. Mini Rev Med Chem 2021; 20:754-767. [PMID: 31686637 DOI: 10.2174/1389557519666191104110908] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/02/2019] [Accepted: 09/02/2019] [Indexed: 12/15/2022]
Abstract
Parkinson's Disease (PD) is the second most common neurodegenerative disease in the elderly population, with a higher prevalence in men, independent of race and social class; it affects approximately 1.5 to 2.0% of the elderly population over 60 years and 4% for those over 80 years of age. PD is caused by the necrosis of dopaminergic neurons in the substantia nigra, which is the brain region responsible for the synthesis of the neurotransmitter dopamine (DA), resulting in its decrease in the synaptic cleft. The monoamine oxidase B (MAO-B) degrades dopamine, promoting the glutamate accumulation and oxidative stress with the release of free radicals, causing excitotoxicity. The PD symptoms are progressive physical limitations such as rigidity, bradykinesia, tremor, postural instability and disability in functional performance. Considering that there are no laboratory tests, biomarkers or imaging studies to confirm the disease, the diagnosis of PD is made by analyzing the motor features. There is no cure for PD, and the pharmacological treatment consists of a dopaminergic supplement with levodopa, COMT inhibitors, anticholinergics agents, dopaminergic agonists, and inhibitors of MAO-B, which basically aims to control the symptoms, enabling better functional mobility and increasing life expectancy of the treated PD patients. Due to the importance and increasing prevalence of PD in the world, this study reviews information on the pathophysiology, symptomatology as well as the most current and relevant treatments of PD patients.
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Affiliation(s)
- Bianca L B Marino
- Laboratorio de Quimica Farmaceutica e Medicinal (PharMedChem), Universidade Federal do Amapa, Macapa, Amapa, Brazil
| | - Lucilene R de Souza
- Laboratorio de Quimica Farmaceutica e Medicinal (PharMedChem), Universidade Federal do Amapa, Macapa, Amapa, Brazil
| | - Kessia P A Sousa
- Laboratorio de Quimica Farmaceutica e Medicinal (PharMedChem), Universidade Federal do Amapa, Macapa, Amapa, Brazil
| | - Jaderson V Ferreira
- Laboratorio de Quimica Farmaceutica e Medicinal (PharMedChem), Universidade Federal do Amapa, Macapa, Amapa, Brazil
| | - Elias C Padilha
- Faculdade de Ciencias Farmaceuticas, Universidade Estadual Paulista (UNESP), Campus Araraquara, Departamento de Principios Ativos Naturais e Toxicologia, Araraquara, Sao Paulo, Brazil
| | - Carlos H T P da Silva
- Laboratório Computacional de Química Farmacêutica, Departamento de Ciências Farmacêuticas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Chemistry, School of Philosophy, Sciences and Letters of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Carlton A Taft
- Centro Brasileiro de Pesquisas Fisicas, Rio de Janeiro, Brazil
| | - Lorane I S Hage-Melim
- Laboratorio de Quimica Farmaceutica e Medicinal (PharMedChem), Universidade Federal do Amapa, Macapa, Amapa, Brazil
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72
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Franzini A, Moosa S, Prada F, Elias WJ. Ultrasound Ablation in Neurosurgery: Current Clinical Applications and Future Perspectives. Neurosurgery 2020; 87:1-10. [PMID: 31745558 DOI: 10.1093/neuros/nyz407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/21/2019] [Indexed: 11/14/2022] Open
Abstract
The concept of focusing high-intensity ultrasound beams for the purpose of cerebral ablation has interested neurosurgeons for more than 70 yr. However, the need for a craniectomy or a cranial acoustic window hindered the clinical diffusion of this technique. Recent technological advances, including the development of phased-array transducers and magnetic resonance imaging technology, have rekindled the interest in ultrasound for ablative brain surgery and have led to the development of the transcranial magnetic resonance-guided focused ultrasound (MRgFUS) thermal ablation procedure. In the last decade, this method has become increasingly popular, and its clinical applications are broadening. Despite the demonstrated efficacy of MRgFUS, transcranial thermal ablation using ultrasound is limited in that it can target exclusively the central region of the brain where the multiple acoustic beams are most optimally focused. On the contrary, lesioning of the cortex, the superficial subcortical areas, and regions close to the skull base is not possible with the limited treatment envelope of current phased-array transducers. Therefore, new ultrasound ablative techniques, which are not based on thermal mechanisms, have been developed and tested in experimental settings. This review describes the mechanisms by which these novel, nonthermal ablative techniques are based and also presents the current clinical applications of MRgFUS thermal ablation.
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Affiliation(s)
- Andrea Franzini
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.,Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Shayan Moosa
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Francesco Prada
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.,Focused Ultrasound Foundation, Charlottesville, Virginia
| | - W Jeffrey Elias
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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73
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McDannold N, Jason White P, Rees Cosgrove G. MRI-based thermal dosimetry based on single-slice imaging during focused ultrasound thalamotomy. Phys Med Biol 2020; 65:235018. [PMID: 32916666 PMCID: PMC8019066 DOI: 10.1088/1361-6560/abb7c4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Transcranial MRI-guided focused ultrasound (MRgFUS) is a noninvasive thermal ablation method approved for the treatment of essential tremor and tremor-dominant Parkinson's disease. This method uses MR temperature imaging (MRTI) to monitor the treatment. Accurately tracking the accumulated thermal dose is important for both safety and efficacy. Currently, MRTI is obtained in a single plane that varies between sonications, preventing direct tracking of the accumulated dose. In this work, we tested a method to estimate this dose during 120 MRgFUS treatments. This method used the MRTI to create simulated thermal images for sonications when the imaging plane was changed. This approach accurately predicted the lesion shapes. The mean Sørensen-Dice similarity coefficient between the lesion segmentations and dose regions at the 17 cumulative min at 43 °C (CEM43) threshold used by the device software was 0.82 but varied among different treatments (range: 0.34-0.95). Tissue swelling appeared to explain when mismatch occurred, although other errors probably contributed. Overall, the mean distance between the lesion segmentations and the 17 CEM43 dose contours was 0.37 ± 0.57 mm. The probability for thermal damage was estimated to be 50% at 13.6 CEM43 and a maximum temperature of 48.6 °C. Due to large thermal gradients, which exceeded 99 CEM43/mm on average, the area where the probability for thermal damage was uncertain was narrow. Overall these results show that the 17 CEM43 threshold is on average a good predictor for thermal lesions, although there will always be a narrow margin where the fate of the tissue is uncertain.
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Affiliation(s)
- Nathan McDannold
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America
| | - P Jason White
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America
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74
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Ibrahim MF, Beevis JC, Empson RM. Essential Tremor - A Cerebellar Driven Disorder? Neuroscience 2020; 462:262-273. [PMID: 33212218 DOI: 10.1016/j.neuroscience.2020.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 10/23/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
Abnormal tremors are the most common of all movement disorders. In this review we focus on the role of the cerebellum in Essential Tremor, a highly debilitating but poorly treated movement disorder. We propose a variety of mechanisms driving abnormal burst firing of deep cerebellar nuclei neurons as a key initiator of tremorgenesis in Essential Tremor. Targetting these mechanisms may generate more effective treatments for Essential Tremor.
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Affiliation(s)
- Mohamed Fasil Ibrahim
- Department of Physiology, School of Biomedical Sciences, University of Otago, Dunedin 9016, New Zealand.
| | - Jessica C Beevis
- Department of Physiology, School of Biomedical Sciences, University of Otago, Dunedin 9016, New Zealand
| | - Ruth M Empson
- Department of Physiology, School of Biomedical Sciences, University of Otago, Dunedin 9016, New Zealand
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75
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Wang KL, Ren Q, Chiu S, Patel B, Meng FG, Hu W, Shukla AW. Deep brain stimulation and other surgical modalities for the management of essential tremor. Expert Rev Med Devices 2020; 17:817-833. [PMID: 33081571 DOI: 10.1080/17434440.2020.1806709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Surgical treatments are considered for essential tremor (ET) when patients do not respond to oral pharmacological therapies. These treatments mainly comprise radiofrequency (RF) thalamotomy, gamma knife radiosurgery (GKRS), deep brain stimulation (DBS), and focused ultrasound (FUS) procedures. AREAS COVERED We reviewed the strengths and weaknesses of each procedure and clinical outcomes for 7 RF studies (n = 85), 11 GKRS (n = 477), 33 DBS (n = 1061), and 13 FUS studies (n = 368). A formal comparison was not possible given the heterogeneity in studies. Improvements were about 42%-90% RF, 10%-79% GKRS, 45%-83% DBS, 42%-83% FUS at short-term follow-up (<12 months) and were about 54%-82% RF, 11%-84% GKRS, 18%-92% DBS, and 42%-80% FUS at long-term follow-up (>12 months). EXPERT OPINION We found DBS with inherent advantages of being an adjustable and reversible procedure as the most frequently employed surgical procedure for control of ET symptoms. FUS is a promising procedure but has limited applicability for unilateral control of symptoms. RF is invasive, and GKRS has unpredictable delayed effects. Each of these surgical modalities has advantages and limitations that need consideration when selecting a treatment for the ET patients.
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Affiliation(s)
- Kai-Liang Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University , Beijing, China.,Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Qianwei Ren
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Shannon Chiu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Bhavana Patel
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Fan-Gang Meng
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Wei Hu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
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76
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Vissani M, Isaias IU, Mazzoni A. Deep brain stimulation: a review of the open neural engineering challenges. J Neural Eng 2020; 17:051002. [PMID: 33052884 DOI: 10.1088/1741-2552/abb581] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an established and valid therapy for a variety of pathological conditions ranging from motor to cognitive disorders. Still, much of the DBS-related mechanism of action is far from being understood, and there are several side effects of DBS whose origin is unclear. In the last years DBS limitations have been tackled by a variety of approaches, including adaptive deep brain stimulation (aDBS), a technique that relies on using chronically implanted electrodes on 'sensing mode' to detect the neural markers of specific motor symptoms and to deliver on-demand or modulate the stimulation parameters accordingly. Here we will review the state of the art of the several approaches to improve DBS and summarize the main challenges toward the development of an effective aDBS therapy. APPROACH We discuss models of basal ganglia disorders pathogenesis, hardware and software improvements for conventional DBS, and candidate neural and non-neural features and related control strategies for aDBS. MAIN RESULTS We identify then the main operative challenges toward optimal DBS such as (i) accurate target localization, (ii) increased spatial resolution of stimulation, (iii) development of in silico tests for DBS, (iv) identification of specific motor symptoms biomarkers, in particular (v) assessing how LFP oscillations relate to behavioral disfunctions, and (vi) clarify how stimulation affects the cortico-basal-ganglia-thalamic network to (vii) design optimal stimulation patterns. SIGNIFICANCE This roadmap will lead neural engineers novel to the field toward the most relevant open issues of DBS, while the in-depth readers might find a careful comparison of advantages and drawbacks of the most recent attempts to improve DBS-related neuromodulatory strategies.
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Affiliation(s)
- Matteo Vissani
- The BioRobotics Institute, Scuola Superiore Sant'Anna, 56025 Pisa, Italy. Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, 56025 Pisa, Italy
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77
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Sharma VD, Patel M, Miocinovic S. Surgical Treatment of Parkinson's Disease: Devices and Lesion Approaches. Neurotherapeutics 2020; 17:1525-1538. [PMID: 33118132 PMCID: PMC7851282 DOI: 10.1007/s13311-020-00939-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 10/23/2022] Open
Abstract
Surgical treatments have transformed the management of Parkinson's disease (PD). Therapeutic options available for the management of PD motor complications include deep brain stimulation (DBS), ablative or lesioning procedures (pallidotomy, thalamotomy, subthalamotomy), and dopaminergic medication infusion devices. The decision to pursue these advanced treatment options is typically done by a multidisciplinary team by considering factors such as the patient's clinical characteristics, efficacy, ease of use, and risks of therapy with a goal to improve PD symptoms and quality of life. DBS has become the most widely used surgical therapy, although there is a re-emergence of interest in ablative procedures with the introduction of MR-guided focused ultrasound. In this article, we review DBS and lesioning procedures for PD, including indications, selection process, and management strategies.
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Affiliation(s)
- Vibhash D Sharma
- Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Blvd, MS 3042, Kansas City, KS, 66160, USA.
| | - Margi Patel
- Department of Neurology, Emory University, Atlanta, GA, USA
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Abstract
Essential tremor is one of the most common tremor syndromes. According to the recent tremor classification, tremor as a symptom is defined as an involuntary, rhythmic, oscillatory movement of a body part and is classified along two axes: axis 1-defining syndromes based on the clinical features such as historical features, tremor characteristics, associated signs, and laboratory tests; and axis 2-classifying the etiology (Bhatia et al., Mov Disord 33:75-87, 2018). The management of this condition has two major approaches. The first is to exclude treatable etiologies, as particularly during the onset of this condition the presentation of a variety of etiologies can be with monosymptomatic tremor. Once the few etiologies with causal treatments are excluded, all further treatment is symptomatic. Shared decision-making with enabling the patient to knowledgeably choose treatment options is needed to customize the management. Mild to moderate tremor severity can sometimes be controlled with occupational treatment, speech therapy of psychotherapy, or adaptation of coping strategy. First-line pharmacological treatments include symptomatic treatment with propranolol, primidone, and topiramate. Botulinum toxin is for selected cases. Invasive treatments for essential tremor should be considered for severe tremors. They are generally accepted as the most powerful interventions and provide not only improvement of tremor but also a significant improvement of life quality. The current standard is deep brain stimulation (DBS) of the thalamic and subthalamic region. Focused ultrasound thalamotomy is a new therapy attracting increasing interest. Radiofrequency lesioning is only rarely done if DBS or focused ultrasound is not possible. Radiosurgery is not well established. We present our treatment algorithm.
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Affiliation(s)
- Franziska Hopfner
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Rosalind-Fraenklinstr. 10, 24105, Kiel, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Günther Deuschl
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Rosalind-Fraenklinstr. 10, 24105, Kiel, Germany.
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79
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Maimbourg G, Guilbert J, Bancel T, Houdouin A, Raybaud G, Tanter M, Aubry JF. Computationally Efficient Transcranial Ultrasonic Focusing: Taking Advantage of the High Correlation Length of the Human Skull. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2020; 67:1993-2002. [PMID: 32396081 DOI: 10.1109/tuffc.2020.2993718] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The phase correction necessary for transcranial ultrasound therapy requires numerical simulation to noninvasively assess the phase shift induced by the skull bone. Ideally, the numerical simulations need to be fast enough for clinical implementation in a brain therapy protocol and to provide accurate estimation of the phase shift to optimize the refocusing through the skull. In this article, we experimentally performed transcranial ultrasound focusing at 900 kHz on N = 5 human skulls. To reduce the computation time, we propose here to perform the numerical simulation at 450 kHz and use the corresponding phase shifts experimentally at 900 kHz. We demonstrate that a 450-kHz simulation restores 94.2% of the pressure when compared with a simulation performed at 900 kHz and 85.0% of the gold standard pressure obtained by an invasive time reversal procedure based on the signal recorded by a hydrophone placed at the target. From a 900- to 450-kHz simulation, the grid size is divided by 8, and the computation time is divided by 10.
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80
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Wüllner U. [Magnetic resonance tomography controlled focused ultrasound (MRgFUS) for tremor]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2020; 88:582-585. [PMID: 32957143 DOI: 10.1055/a-1227-6211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Treatment of tremor is a challenge in everyday clinical practice; tremor in movement disorders such as essential or orthostatic tremor (ET, OT) or Parkinson's disease (PD) can rarely be treated sufficiently with oral medication. An alternative to deep brain stimulation is the targeted local lesion of specific structures of the thalamus and basal ganglia by means of transcranial magnetic resonance imaging guided focused ultrasound (MRgFUS). MRgFUS allows to thermally ablate small areas of the brain safely and precisely. MRgFUS treatments are performed without opening of the skull under MRI control ('incisionless surgery'). This minimal invasive procedure can improve the often severely impaired quality of life of the mostly elderly patients on a day to day basis without the need for long in-patient procedures. A sustained effect of the lesion treatment has so far been investigated and documented over 4 years.
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Affiliation(s)
- Ullrich Wüllner
- Neurologie, Universitatsklinikum Bonn, Deutsches Zentrum fur Neurodegenerative Erkrankungen, Klinische Forschung
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81
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Sinai A, Nassar M, Eran A, Constantinescu M, Zaaroor M, Sprecher E, Schlesinger I. Magnetic resonance-guided focused ultrasound thalamotomy for essential tremor: a 5-year single-center experience. J Neurosurg 2020; 133:417-424. [PMID: 31277064 DOI: 10.3171/2019.3.jns19466] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors report their experience in treating patients suffering from medication-resistant essential tremor (ET) with MR-guided focused ultrasound (MRgFUS) thalamotomy over a 5-year period. METHODS Forty-four ET patients treated with unilateral MRgFUS ventral intermediate nucleus (VIM) thalamotomy were assessed using the Clinical Rating Scale for Tremor (CRST) score and the Quality of Life in Essential Tremor Questionnaire (QUEST) over a 5-year span. RESULTS Tremor was significantly improved immediately following MRgFUS in all patients and ceased completely in 24 patients. CRST scores in the treated hand at baseline (median 19; range 7-32, 44 patients) improved by a median of 16 at 1 month (44 patients; p < 0.0001), 17 at 6 months (31 patients; p < 0.0001), 15 at 1 year (24 patients; p < 0.0001), 18 at 2 years (15 patients; p < 0.0001), 19 at 3 years, (10 patients; p < 0.0001), 21 at 4 years (6 patients; p < 0.01), and 23 at 5 years (2 patients, significance not tested). Return of tremor that impacted activities of daily living was reported in 5 patients (11%). QUEST scores showed significant improvement, with median change of 35 points (p < 0.0001; 44 patients) at 1 month, 33 (p < 0.0001; 31 patients) at 6 months, 27 (p < 0.0001; 24 patients) at 1 year, 26 (p < 0.001; 15 patients) at 2 years, 25 (p < 0.001; 10 patients) at 3 years, 33 (p < 0.001; 6 patients) at 4 years, and 28 (significance not tested, 2 patients) at 5 years. Adverse events after the procedure were reversible in all but 5 patients (11%). CONCLUSIONS MRgFUS thalamotomy for ET is an effective and safe procedure that provides long-term tremor relief and improvement in quality of life even in patients with medication-resistant disabling tremor. Additional studies with a larger group of patients is needed to substantiate these favorable results.
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Affiliation(s)
| | | | - Ayelet Eran
- 3Radiology, Rambam Health Care Campus, Haifa; and
- 4Technion Faculty of Medicine, Haifa, Israel
| | | | - Menashe Zaaroor
- Departments of1Neurosurgery
- 4Technion Faculty of Medicine, Haifa, Israel
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Parker WE, Weidman EK, Chazen JL, Niogi SN, Uribe-Cardenas R, Kaplitt MG, Hoffman CE. Magnetic resonance-guided focused ultrasound for ablation of mesial temporal epilepsy circuits: modeling and theoretical feasibility of a novel noninvasive approach. J Neurosurg 2020; 133:63-70. [PMID: 31200385 DOI: 10.3171/2019.4.jns182694] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 04/05/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The authors tested the feasibility of magnetic resonance-guided focused ultrasound (MRgFUS) ablation of mesial temporal lobe epilepsy (MTLE) seizure circuits. Up to one-third of patients with mesial temporal sclerosis (MTS) suffer from medically refractory epilepsy requiring surgery. Because current options such as open resection, laser ablation, and Gamma Knife radiosurgery pose potential risks, such as infection, hemorrhage, and ionizing radiation, and because they often produce visual or neuropsychological deficits, the authors developed a noninvasive MRgFUS ablation strategy for mesial temporal disconnection to mitigate these risks. METHODS The authors retrospectively reviewed 3-T MRI scans obtained with diffusion tensor imaging (DTI). The study group included 10 patients with essential tremor (ET) who underwent pretreatment CT and MRI prior to MRgFUS, and 2 patients with MTS who underwent MRI. Fiber tracking of the fornix-fimbria pathway and inferior optic radiations was performed, ablation sites mimicking targets of open posterior hippocampal disconnection were modeled, and theoretical MRgFUS surgical plans were devised. Distances between the targets and optic radiations were measured, helmet angulations were prescribed, and the numbers of available MRgFUS array elements were calculated. RESULTS Tractograms of fornix-fimbria and optic radiations were generated in all ET and MTS patients successfully. Of the 10 patients with both the CT and MRI data necessary for the analysis, 8 patients had adequate elements available to target the ablation site. A margin (mean 8.5 mm, range 6.5-9.8 mm) of separation was maintained between the target lesion and optic radiations. CONCLUSIONS MRgFUS offers a noninvasive option for seizure tract disruption. DTI identifies fornix-fimbria and optic radiations to localize optimal ablation targets and critical surrounding structures, minimizing risk of postoperative visual field deficits. This theoretical modeling study provides the necessary groundwork for future clinical trials to apply this novel neurosurgical technique to patients with refractory MTLE and surgical contraindications, multiple prior surgeries, or other factors favoring noninvasive treatment.
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Affiliation(s)
| | - Elizabeth K Weidman
- 2Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - J Levi Chazen
- 2Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Sumit N Niogi
- 2Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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83
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MRI follow-up after magnetic resonance-guided focused ultrasound for non-invasive thalamotomy: the neuroradiologist's perspective. Neuroradiology 2020; 62:1111-1122. [PMID: 32363482 PMCID: PMC7410861 DOI: 10.1007/s00234-020-02433-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/07/2020] [Indexed: 11/29/2022]
Abstract
Purpose Magnetic resonance-guided focused ultrasound (MRgFUS) systems are increasingly used to non-invasively treat tremor; consensus on imaging follow-up is poor in these patients. This study aims to elucidate how MRgFUS lesions evolve for a radiological readership with regard to clinical outcome. Methods MRgFUS-induced lesions and oedema were retrospectively evaluated based on DWI, SWI, T2-weighted and T1-weighted 3-T MRI data acquired 30 min and 3, 30 and 180 days after MRgFUS (n = 9 essential tremor, n = 1 Parkinson’s patients). Lesions were assessed volumetrically, visually and by ADC measurements and compared with clinical effects using non-parametric testing. Results Thirty minutes after treatment, all lesions could be identified on T2-weighted images. Immediate oedema was rare (n = 1). Lesion volume as well as oedema reached a maximum on day 3 with a mean lesion size of 0.4 ± 0.2 cm3 and an oedema volume 3.7 ± 1.2 times the lesion volume. On day 3, a distinct diffusion-restricted rim was noted that corresponded well with SWI. Lesion shrinkage after day 3 was observed in all sequences. Lesions were no longer detectable on DWI in n = 7/10, on T2-weighted images in n = 4/10 and on T1-weighted images in n = 4/10 on day 180. No infarcts or haemorrhage were observed. There was no correlation between lesion size and initial motor skill improvement (p = 0.99). Tremor reduction dynamics correlated strongly with lesion shrinkage between days 3 and 180 (p = 0.01, R = 0.76). Conclusion In conclusion, cerebral MRgFUS lesions variably shrink over months. SWI is the sequence of choice to identify lesions after 6 months. Lesion volume is arguably associated with intermediate-term outcome.
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Gagliardo C, Cannella R, Quarrella C, D'Amelio M, Napoli A, Bartolotta TV, Catalano C, Midiri M, Lagalla R. Intraoperative imaging findings in transcranial MR imaging-guided focused ultrasound treatment at 1.5T may accurately detect typical lesional findings correlated with sonication parameters. Eur Radiol 2020; 30:5059-5070. [PMID: 32346791 DOI: 10.1007/s00330-020-06712-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/28/2019] [Accepted: 02/04/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess the intraoperative neuroimaging findings in patients treated with transcranial MR-guided focused ultrasound (tcMRgFUS) thalamotomy using 1.5T equipment in comparison with the 48-h follow-up. METHODS Fifty prospectively enrolled patients undergoing unilateral tcMRgFUS thalamotomy for either medication-refractory essential tremor (n = 39) or Parkinson tremor (n = 11) were included. Two radiologists evaluated the presence and size of concentric lesional zones (zone I, zone II, and zone III) on 2D T2-weighted sequences acquired intraoperatively after the last high-energy sonication and at 48 h. Sonication parameters including number of sonications, delivered energy, and treatment temperatures were also recorded. Differences in lesion pattern and size were assessed using the McNemar test and paired t test, respectively. RESULTS Zones I, II, and III were visualized in 34 (68%), 50 (100%), and 44 (88%) patients, and 31 (62%), 50 (100%), and 45 (90%) patients after the last high-energy sonication for R1 and R2, respectively. All three concentric zones were visualized intraoperatively in 56-58% of cases. Zone I was significantly more commonly visualized at 48 h (p < 0.001). Diameter of zones I and II and the thickness of zone III significantly increased at 48 h (p < 0.001). Diameters of zones I and II measured intraoperatively demonstrated significant correlation with thermal map temperatures (p ≤ 0.001). Maximum temperature significantly correlated with zone III thickness at 48 h. A threshold of 60.5° had a sensitivity of 56.5-66.7% and a specificity of 70.5-75.5% for thickness > 6 mm at 48 h. CONCLUSIONS Intraoperative imaging may accurately detect typical lesional findings, before completing the treatment. These imaging characteristics significantly correlate with sonication parameters and 48-h follow-up. KEY POINTS • Intraoperative T2-weighted images allow the visualization of the zone I (coagulation necrosis) in most of the treated patients, while zone II (cytotoxic edema) is always detected. • Lesion size depicted with intraoperative transcranial MRgFUS imaging correlates well with procedure parameters. • Intraoperative transcranial MRgFUS imaging may have a significant added value for treating physicians.
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Affiliation(s)
- Cesare Gagliardo
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Cettina Quarrella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Marco D'Amelio
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Alessandro Napoli
- Department of Radiological, Oncological and Anatomopathological Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Tommaso Vincenzo Bartolotta
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Anatomopathological Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Massimo Midiri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Roberto Lagalla
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
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Anesthesia considerations of magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: a case series. Can J Anaesth 2020; 67:877-884. [PMID: 32291631 DOI: 10.1007/s12630-020-01644-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Essential tremor (ET) is a common movement disorder with disability in voluntary actions such as eating and writing. First-line treatment involves pharmacological agents, although efficacy is limited by side effects. In these patients, functional neurosurgery can be considered. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy offers a non-invasive solution for treatment. This paper examines an original cohort of ET patients undergoing MRgFUS thalamotomy and discusses the anesthetic management of these cases. METHODS We retrospectively reviewed the anesthetic records of all MRgFUS thalamotomy cases from 15 May 2012 to 16 July 2015 at our centre (Sunnybrook Health Sciences Centre, Toronto, Canada) to expand a data set provided by the focused ultrasound system manufacturer (Insightec, Tirat Carmel, Israel) from a prior phase-II regulatory approval study. Specific drug and procedural details were listed including aspects of the patients' experience. RESULTS A total of 82 patients were included in the analysis, 78 from a phase-II trial (16 were from the local site) and four local non-trial cases. No patient required general anesthesia and only 29% of cases required sedation to tolerate the procedure. The most frequent medications required were antiemetics and analgesics. Headache (31%) was the most frequent perioperative symptom. Transient intra-procedural paresthesia symptoms were a common occurrence (32%). CONCLUSIONS The use of MRgFUS for thalamotomy provides a non-invasive and well-tolerated method for treating ET, which usually only requires monitored anesthesia care sedation. Nevertheless, there are several predictable side effects that require contingency planning including the personnel and means to resolve them.
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Bruno F, Catalucci A, Arrigoni F, Sucapane P, Cerone D, Cerrone P, Ricci A, Marini C, Masciocchi C. An experience-based review of HIFU in functional interventional neuroradiology: transcranial MRgFUS thalamotomy for treatment of tremor. Radiol Med 2020; 125:877-886. [PMID: 32266693 DOI: 10.1007/s11547-020-01186-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/24/2020] [Indexed: 12/16/2022]
Abstract
Tremor is a common and very disabling symptom in patients with essential tremor and Parkinson's disease. In the recent years, transcranial ablation of thalamic nuclei using magnetic resonance guided high-intensity focused ultrasound has emerged as a minimally invasive treatment for tremor. The aim of this review is to discuss, in the light of our single-center experience, the technique, current applications, results, and future perspectives of this novel technology.
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Affiliation(s)
- Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, via Vetoio 1, 67100, L'Aquila, Italy.
| | | | - Francesco Arrigoni
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, via Vetoio 1, 67100, L'Aquila, Italy
| | | | - Davide Cerone
- Neurology Unit, San Salvatore Hospital, L'Aquila, Italy
| | - Paolo Cerrone
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, via Vetoio 1, 67100, L'Aquila, Italy
| | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore Hospital, L'Aquila, Italy
| | - Carmine Marini
- Neurology Unit, Department of Medicine, Health and Environment Sciences, L'Aquila, Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, via Vetoio 1, 67100, L'Aquila, Italy
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87
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Zur G, Lesman-Segev OH, Schlesinger I, Goldsher D, Sinai A, Zaaroor M, Assaf Y, Eran A, Kahn I. Tremor Relief and Structural Integrity after MRI-guided Focused US Thalamotomy in Tremor Disorders. Radiology 2020; 294:676-685. [DOI: 10.1148/radiol.2019191624] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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88
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Greene DJ, Marek S, Gordon EM, Siegel JS, Gratton C, Laumann TO, Gilmore AW, Berg JJ, Nguyen AL, Dierker D, Van AN, Ortega M, Newbold DJ, Hampton JM, Nielsen AN, McDermott KB, Roland JL, Norris SA, Nelson SM, Snyder AZ, Schlaggar BL, Petersen SE, Dosenbach NUF. Integrative and Network-Specific Connectivity of the Basal Ganglia and Thalamus Defined in Individuals. Neuron 2020; 105:742-758.e6. [PMID: 31836321 PMCID: PMC7035165 DOI: 10.1016/j.neuron.2019.11.012] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/28/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
The basal ganglia, thalamus, and cerebral cortex form an interconnected network implicated in many neurological and psychiatric illnesses. A better understanding of cortico-subcortical circuits in individuals will aid in development of personalized treatments. Using precision functional mapping-individual-specific analysis of highly sampled human participants-we investigated individual-specific functional connectivity between subcortical structures and cortical functional networks. This approach revealed distinct subcortical zones of network specificity and multi-network integration. Integration zones were systematic, with convergence of cingulo-opercular control and somatomotor networks in the ventral intermediate thalamus (motor integration zones), dorsal attention and visual networks in the pulvinar, and default mode and multiple control networks in the caudate nucleus. The motor integration zones were present in every individual and correspond to consistently successful sites of deep brain stimulation (DBS; essential tremor). Individually variable subcortical zones correspond to DBS sites with less consistent treatment effects, highlighting the importance of PFM for neurosurgery, neurology, and psychiatry.
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Affiliation(s)
- Deanna J Greene
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Scott Marek
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Evan M Gordon
- VISN17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; Center for Vital Longevity, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA; Department of Psychology and Neuroscience, Baylor University, Waco, TX, USA
| | - Joshua S Siegel
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Caterina Gratton
- Department of Psychology, Northwestern University, Evanston, IL, USA; Department of Neurology, Northwestern University, Evanston, IL, USA
| | - Timothy O Laumann
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Adrian W Gilmore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Jeffrey J Berg
- Department of Psychology, New York University, New York, NY, USA
| | - Annie L Nguyen
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Donna Dierker
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew N Van
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Mario Ortega
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Dillan J Newbold
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jacqueline M Hampton
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashley N Nielsen
- Institute for Innovations in Developmental Sciences, Northwestern University, Chicago, IL, USA
| | - Kathleen B McDermott
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Psychological and Brain Sciences, Washington University, St. Louis, MO, USA
| | - Jarod L Roland
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Scott A Norris
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M Nelson
- VISN17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; Center for Vital Longevity, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA; Department of Psychology and Neuroscience, Baylor University, Waco, TX, USA
| | - Abraham Z Snyder
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Bradley L Schlaggar
- Kennedy Krieger Institute, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven E Petersen
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA; Department of Neuroscience, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University, St. Louis, MO, USA
| | - Nico U F Dosenbach
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA; Program in Occupational Therapy, Washington University, St. Louis, MO, USA.
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Duc NM, Keserci B. Emerging clinical applications of high-intensity focused ultrasound. ACTA ACUST UNITED AC 2020; 25:398-409. [PMID: 31287428 DOI: 10.5152/dir.2019.18556] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
High-intensity focused ultrasound (HIFU) is a minimally-invasive and non-ionizing promising technology and has been assessed for its role in the treatment of not only primary tumors but also metastatic lesions under the guidance of ultrasound or magnetic resonance imaging. Its performance is notably effective in neurologic, genitourinary, hepato-pancreato-biliary, musculoskeletal, oncologic, and other miscellaneous applications. In this article, we reviewed the emerging technology of HIFU and its clinical applications.
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Affiliation(s)
- Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Bilgin Keserci
- Department of Radiology, Universiti Sains Malaysia School of Medical Sciences, Kelantan, Malaysia; Department of Radiology, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
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90
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Tohyama S, Walker MR, Sammartino F, Krishna V, Hodaie M. The Utility of Diffusion Tensor Imaging in Neuromodulation: Moving Beyond Conventional Magnetic Resonance Imaging. Neuromodulation 2020; 23:427-435. [DOI: 10.1111/ner.13107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/08/2019] [Accepted: 01/02/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Sarasa Tohyama
- Division of Brain, Imaging, and Behaviour–Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital University Health Network Toronto ON Canada
- Institute of Medical Science, Faculty of Medicine University of Toronto Toronto ON Canada
| | - Matthew R. Walker
- Division of Brain, Imaging, and Behaviour–Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital University Health Network Toronto ON Canada
| | - Francesco Sammartino
- Center for Neuromodulation, Department of Neurosurgery The Ohio State University Columbus OH USA
| | - Vibhor Krishna
- Center for Neuromodulation, Department of Neurosurgery The Ohio State University Columbus OH USA
| | - Mojgan Hodaie
- Division of Brain, Imaging, and Behaviour–Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital University Health Network Toronto ON Canada
- Institute of Medical Science, Faculty of Medicine University of Toronto Toronto ON Canada
- Department of Surgery, Faculty of Medicine University of Toronto Toronto ON Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital University Health Network Toronto ON Canada
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91
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Izadifar Z, Izadifar Z, Chapman D, Babyn P. An Introduction to High Intensity Focused Ultrasound: Systematic Review on Principles, Devices, and Clinical Applications. J Clin Med 2020; 9:jcm9020460. [PMID: 32046072 PMCID: PMC7073974 DOI: 10.3390/jcm9020460] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 01/29/2020] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Ultrasound can penetrate deep into tissues and interact with human tissue via thermal and mechanical mechanisms. The ability to focus an ultrasound beam and its energy onto millimeter-size targets was a significant milestone in the development of therapeutic applications of focused ultrasound. Focused ultrasound can be used as a non-invasive thermal ablation technique for tumor treatment and is being developed as an option to standard oncologic therapies. High-intensity focused ultrasound has now been used for clinical treatment of a variety of solid malignant tumors, including those in the pancreas, liver, kidney, bone, prostate, and breast, as well as uterine fibroids and soft-tissue sarcomas. Magnetic resonance imaging and Ultrasound imaging can be combined with high intensity focused ultrasound to provide real-time imaging during ablation. Magnetic resonance guided focused ultrasound represents a novel non-invasive method of treatment that may play an important role as an alternative to open neurosurgical procedures for treatment of a number of brain disorders. This paper briefly reviews the underlying principles of HIFU and presents current applications, outcomes, and complications after treatment. Recent applications of Focused ultrasound for tumor treatment, drug delivery, vessel occlusion, histotripsy, movement disorders, and vascular, oncologic, and psychiatric applications are reviewed, along with clinical challenges and potential future clinical applications of HIFU.
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Affiliation(s)
- Zahra Izadifar
- Division of Biomedical Engineering, College of Engineering, University of Saskatchewan, Saskatoon, SK S7N 5A9, Canada
- Correspondence: ; Tel.: +1-306-966-7827; Fax: +1-306-966-4651
| | - Zohreh Izadifar
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA
| | - Dean Chapman
- Anatomy & Cell Biology, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
| | - Paul Babyn
- Department of Medical Imaging, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada
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92
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Gallay MN, Moser D, Rossi F, Magara AE, Strasser M, Bühler R, Kowalski M, Pourtehrani P, Dragalina C, Federau C, Jeanmonod D. MRgFUS Pallidothalamic Tractotomy for Chronic Therapy-Resistant Parkinson's Disease in 51 Consecutive Patients: Single Center Experience. Front Surg 2020; 6:76. [PMID: 31993437 PMCID: PMC6971056 DOI: 10.3389/fsurg.2019.00076] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background: There is a long history, beginning in the 1940s, of ablative neurosurgery on the pallidal efferent fibers to treat patients suffering from Parkinson's disease (PD). Since the early 1990s, we undertook a re-actualization of the approach to the subthalamic region, and proposed, on a histological basis, to target specifically the pallidothalamic tract at the level of Forel's field H1. This intervention, the pallidothalamic tractotomy (PTT), has been performed since 2011 using the MR-guided focused ultrasound (MRgFUS) technique. A reappraisal of the histology of the pallidothalamic tract was combined recently with an optimization of our lesioning strategy using thermal dose control. Objective: This study was aimed at demonstrating the efficacy and risk profile of MRgFUS PTT against chronic therapy-resistant PD. Methods: This consecutive case series reflects our current treatment routine and was collected between 2017 and 2018. Fifty-two interventions in 47 patients were included. Fifteen patients received bilateral PTT. The median follow-up was 12 months. Results: The Unified Parkinson's Disease Rating Scale (UPDRS) off-medication postoperative score was compared to the baseline on-medication score and revealed percentage reductions of the mean of 84% for tremor, 70% for rigidity, and 73% for distal hypobradykinesia, all values given for the treated side. Axial items (for voice, trunk and gait) were not significantly improved. PTT achieved 100% suppression of on-medication dyskinesias as well as reduction in pain (p < 0.001), dystonia (p < 0.001) and REM sleep disorders (p < 0.01). Reduction of the mean L-Dopa intake was 55%. Patients reported an 88% mean tremor relief and 82% mean global symptom relief on the operated side and 69% mean global symptom improvement for the whole body. There was no significant change of cognitive functions. The small group of bilateral PTTs at 1 year follow-up shows similar results as compared to unilateral PTTs but does not allow to draw firm conclusions at this point. Conclusion: MRgFUS PTT was shown to be a safe and effective intervention for PD patients, addressing all symptoms, with varying effectiveness. We discuss the need to integrate the preoperative state of the thalamocortical network as well as the psycho-emotional dimension.
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Affiliation(s)
- Marc N Gallay
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | - David Moser
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | - Franziska Rossi
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
| | | | - Maja Strasser
- Neurologische Praxis Solothurn, Solothurn, Switzerland
| | - Robert Bühler
- Neurological Division, Bürgerspital Solothurn, Solothurn, Switzerland
| | | | | | | | - Christian Federau
- Department of Radiology, University Hospital Basel, Basel, Switzerland.,Institute for Biomedical Engineering, ETH Zürich, University Zürich, Zurich, Switzerland
| | - Daniel Jeanmonod
- SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland
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93
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Parkinson’s Disease: Lesions. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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94
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Wu A, Halpern C. Essential Tremor: Deep Brain Stimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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95
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Bhansali AP, Gwinn RP. Ablation: Radiofrequency, Laser, and HIFU. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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96
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Pouratian N, Baltuch G, Elias WJ, Gross R. American Society for Stereotactic and Functional Neurosurgery Position Statement on Magnetic Resonance-Guided Focused Ultrasound for the Management of Essential Tremor. Neurosurgery 2019; 87:E126-E129. [DOI: 10.1093/neuros/nyz510] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/19/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Magnetic resonance-guided focused ultrasound thalamotomy is a novel tool in the neurosurgical armamentarium for management of essential tremor (ET). Given the recent introduction of this technology, the American Society of Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, including confirmed diagnosis of ET, failure to respond to first-line therapies, disabling appendicular tremor, and unilateral treatment are detailed, based on current evidence. Contraindications to therapy are also detailed. Finally, the evidence and authority on which the ASSFN bases this consensus position statement is detailed.
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Affiliation(s)
- Nader Pouratian
- Department of Neurosurgery, University of California, Los Angeles, California
| | - Gordon Baltuch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - W Jeff Elias
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert Gross
- Department of Neurosurgery, Emory University, Atlanta, Georgia
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97
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Xu Y, He Q, Wang M, Gao Y, Liu X, Li D, Xiong B, Wang W. Safety and efficacy of magnetic resonance imaging-guided focused ultrasound neurosurgery for Parkinson's disease: a systematic review. Neurosurg Rev 2019; 44:115-127. [PMID: 31814058 DOI: 10.1007/s10143-019-01216-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/06/2019] [Accepted: 11/20/2019] [Indexed: 02/05/2023]
Abstract
Magnetic resonance imaging-guided focused ultrasound (MRgFUS) neurosurgery is a new option for medication-resistant Parkinson's disease (PD), but its safety and efficacy remain elusive. This study aimed to investigate the safety and efficacy of MRgFUS for PD by systematically reviewing related literature. PubMed and EMBASE were searched to identify related studies. Inclusion criteria were (1) reported the efficacy or safety of MRgFUS for PD and (2) published in English. Exclusion criteria were (1) nonhuman study, (2) review or meta-analysis or other literature types without original data, and (3) conference abstract without full text. Data on study characteristics, treatment parameters, efficacy, and adverse events were collected. Descriptive synthesis of data was performed. Eleven studies containing 80 patients were included. Nine studies were observational studies with no controls. Two studies included a randomized and controlled phase. Most studies included tremor-dominant PD. Ten studies reported decline of UPDRS-III scores after MRgFUS, and five reported a statistically significant decline. Nine studies evaluated the quality of life (QOL). Significant improvement of QOL was reported by four studies using the 39-item Parkinson's disease questionnaire. Four studies investigated the impact of MRgFUS on non-motor symptoms. Most tests indicated that MRgFUS had no significant effect on neuropsychological outcomes. Most adverse events were mild and transient. MRgFUS is a potential treatment for PD with satisfying efficacy and safety. Studies in this field are still limited. More studies with strict design, larger sample size, and longer follow-up are needed to further investigate its efficacy and safety for PD.
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Affiliation(s)
- Yangyang Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Qi He
- Department of Neonatology, West China Second University Hospital Sichuan University, Chengdu, 610041, China
| | - Mengqi Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yuan Gao
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xiaowei Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Denghui Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Botao Xiong
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, 610041, China.
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Pandit R, Chen L, Götz J. The blood-brain barrier: Physiology and strategies for drug delivery. Adv Drug Deliv Rev 2019; 165-166:1-14. [PMID: 31790711 DOI: 10.1016/j.addr.2019.11.009] [Citation(s) in RCA: 268] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 12/14/2022]
Abstract
The blood-brain barrier (BBB) is a dynamic structure that functions as a gatekeeper, reflecting the unique requirements of the brain. In this review, following a brief historical overview of how the concepts of the BBB and the neurovascular unit (NVU) developed, we describe its physiology and architecture, which pose a particular challenge to therapeutic intervention. We then discuss how the restrictive nature of this barrier can be overcome for the delivery of therapeutic agents. Alterations to drug formulation offer one option, in part by utilizing distinct transport modes; another is invasive or non-invasive strategies to bypass the BBB. An emerging non-invasive technology for targeted drug delivery is focused ultrasound that allows for the safe and reversible disruption of the BBB. We discuss the underlying mechanisms and provide an outlook, emphasizing the need for more research into the NVU and investment in innovative technologies to overcome the BBB for drug delivery.
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Affiliation(s)
- Rucha Pandit
- Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Liyu Chen
- Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Jürgen Götz
- Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia.
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99
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Rodriguez-Rojas R, Pineda-Pardo JA, Martinez-Fernandez R, Kogan RV, Sanchez-Catasus CA, del Alamo M, Hernández F, García-Cañamaque L, Leenders KL, Obeso JA. Functional impact of subthalamotomy by magnetic resonance–guided focused ultrasound in Parkinson’s disease: a hybrid PET/MR study of resting-state brain metabolism. Eur J Nucl Med Mol Imaging 2019; 47:425-436. [DOI: 10.1007/s00259-019-04497-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/21/2019] [Indexed: 11/29/2022]
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100
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Walker MR, Zhong J, Waspe AC, Looi T, Piorkowska K, Hawkins C, Drake JM, Hodaie M. Acute MR-Guided High-Intensity Focused Ultrasound Lesion Assessment Using Diffusion-Weighted Imaging and Histological Analysis. Front Neurol 2019; 10:1069. [PMID: 31681145 PMCID: PMC6803785 DOI: 10.3389/fneur.2019.01069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/23/2019] [Indexed: 01/03/2023] Open
Abstract
Objectives: The application of magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment of neurological conditions has been of increasing interest. Conventional MR imaging can provide structural information about the effect of MRgFUS, where differences in ablated tissue can be seen, but it lacks information about the status of the cellular environment or neural microstructure. We investigate in vivo acute changes in water diffusion and white matter tracts in the brain of a piglet model after MRgFUS treatment using diffusion-weighted imaging (DWI) with histological verification of treatment-related changes. Methods: MRgFUS was used to treat the anterior body of the fornix in four piglets. T1 and diffusion-weighted images were collected before and after treatment. Mean diffusion-weighted imaging (MDWI) images were generated to measure lesion volumes via signal intensity thresholds. Histological data were collected for volume comparison and assessment of treatment effect. DWI metric maps of fractional anisotropy (FA), apparent diffusion coefficient (ADC), axial diffusivity (AD), radial diffusivity (RD), and mean diffusivity (MD) were generated for quantitative assessment. Fornix-related fiber tracts were generated before and after treatment for qualitative assessment. Results: The volume of treated tissue measured via MDWI did not differ significantly from histological measurements, and both were significantly larger than the treatment cell volume. Diffusion metrics in the treatment region were significantly decreased following MRgFUS treatment, with the peak change seen at the lesion core and decreasing radially. Histological analysis confirmed an area of coagulative necrosis in the targeted region with sharp demarcation zone with surrounding brain. Tractography from the lesion core and the fornix revealed fiber disruptions following treatment. Conclusions: Diffusion maps and fiber tractography are an effective method for assessing lesion volumes and microstructural changes in vivo following MRgFUS treatment. This study demonstrates that DWI has the potential to advance MRgFUS by providing convenient in vivo microstructural lesion and fiber tractography assessment after treatment.
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Affiliation(s)
- Matthew R Walker
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Division of Brain, Imaging and Behaviour - Systems Neuroscience, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Jidan Zhong
- Division of Brain, Imaging and Behaviour - Systems Neuroscience, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Adam C Waspe
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Thomas Looi
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada
| | - Karolina Piorkowska
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada
| | - Cynthia Hawkins
- Department of Paediatric Laboratory Medicine, Division of Neuropathology, Hospital for Sick Children, Toronto, ON, Canada
| | - James M Drake
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Mojgan Hodaie
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Division of Brain, Imaging and Behaviour - Systems Neuroscience, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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