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Bishay AE, Lyons AT, Koester SW, Paulo DL, Liles C, Dambrino RJ, Feldman MJ, Ball TJ, Bick SK, Englot DJ, Chambless LB. Global Economic Evaluation of the Reported Costs of Deep Brain Stimulation. Stereotact Funct Neurosurg 2024:1-17. [PMID: 38513625 DOI: 10.1159/000537865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Despite the known benefits of deep brain stimulation (DBS), the cost of the procedure can limit access and can vary widely. Our aim was to conduct a systematic review of the reported costs associated with DBS, as well as the variability in reporting cost-associated factors to ultimately increase patient access to this therapy. METHODS A systematic review of the literature for cost of DBS treatment was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and Embase databases were queried. Olsen & Associates (OANDA) was used to convert all reported rates to USD. Cost was corrected for inflation using the US Bureau of Labor Statistics Inflation Calculator, correcting to April 2022. RESULTS Twenty-six articles on the cost of DBS surgery from 2001 to 2021 were included. The median number of patients across studies was 193, the mean reported age was 60.5 ± 5.6 years, and median female prevalence was 38.9%. The inflation- and currency-adjusted mean cost of the DBS device was USD 21,496.07 ± USD 8,944.16, the cost of surgery alone was USD 14,685.22 ± USD 8,479.66, the total cost of surgery was USD 40,942.85 ± USD 17,987.43, and the total cost of treatment until 1 year of follow-up was USD 47,632.27 ± USD 23,067.08. There were no differences in costs observed across surgical indication or country. CONCLUSION Our report describes the large variation in DBS costs and the manner of reporting costs. The current lack of standardization impedes productive discourse as comparisons are hindered by both geographic and chronological variations. Emphasis should be put on standardized reporting and analysis of reimbursement costs to better assess the variability of DBS-associated costs in order to make this procedure more cost-effective and address areas for improvement to increase patient access to DBS.
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Affiliation(s)
- Anthony E Bishay
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Stefan W Koester
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Danika L Paulo
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Campbell Liles
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J Dambrino
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael J Feldman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tyler J Ball
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah K Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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2
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Pereira EA, Morgante F, Green AL. Cost effectiveness studies of tremor treatment should not focus on ultrasound while neglecting radiofrequency lesioning. Br J Radiol 2023; 96:20220995. [PMID: 37276147 PMCID: PMC10546462 DOI: 10.1259/bjr.20220995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/07/2023] [Indexed: 06/07/2023] Open
Affiliation(s)
- Erlick A Pereira
- Neurosciences Research Centre, St George’s, University of London, London, United Kingdom
| | - Francesca Morgante
- Neurosciences Research Centre, St George’s, University of London, London, United Kingdom
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, London, United Kingdom
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3
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Mehta NH, Shah HA, Ben-Shalom N, D'Amico RS. Sonolucent cranioplasty: Is therapeutic FUS the next frontier? J Clin Neurosci 2023; 114:129-130. [PMID: 37390776 DOI: 10.1016/j.jocn.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/05/2023] [Accepted: 06/24/2023] [Indexed: 07/02/2023]
Abstract
Focused ultrasound (FUS) has emerged as a promising area of research in neuro-oncology. Preclinical and clinical investigation has demonstrated the utility of FUS in therapeutic applications including blood brain barrier disruption for therapeutic delivery, and high intensity FUS for tumor ablation. However, FUS as it exists today is relatively invasive as implantable devices are necessary to achieve adequate intracranial penetration. Sonolucent implants, composed of materials permeable to acoustic waves, have been used for cranioplasty and intracranial imaging with ultrasound. Given the overlap in ultrasound parameters with those used for intracranial imaging, and the demonstrated efficacy of sonolucent cranial implants, we believe that therapeutic FUS through sonolucent implants represents a promising avenue of future research. The potential applications of FUS and sonolucent cranial implants may confer the demonstrated therapeutic benefits of existing FUS applications, without the drawbacks and complications of invasive implantable devices. Here we briefly summarize existing evidence regarding sonolucent implants and describe applications for therapeutic FUS.
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Affiliation(s)
| | - Harshal A Shah
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Netanel Ben-Shalom
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
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4
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Jameel A, Meiwald A, Bain P, Patel N, Nandi D, Jones B, Weston G, Adams EJ, Gedroyc W. The cost-effectiveness of unilateral magnetic resonance-guided focused ultrasound in comparison with unilateral deep brain stimulation for the treatment of medically refractory essential tremor in England. Br J Radiol 2022; 95:20220137. [PMID: 36125247 PMCID: PMC9733625 DOI: 10.1259/bjr.20220137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 08/01/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This study aims to ascertain the cost-effectiveness of magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment of medically refractory Essential Tremor (mrET) in England. Essential Tremor (ET) is the most common movement disorder affecting approximately 1 million in the UK causing considerable societal impact affecting patients, carers and the wider healthservice. Medical treatment has mixed efficacy, with approximately 25-55% of ET medication refractory. Deep brain stimulation (DBS) is a proven neurosurgical treatment; however, the risks of surgery and anaesthesia mean some patients are ineligible. MRgFUS is an emerging noninvasive technique that causes tremor suppression by thermal ablation of tremor-sensitive brain tissue. Several international clinical trials have demonstrated MRgFUS is safe and clinically effective; however, to-date no cost-effectiveness study has been performed in Europe. METHODS A Markov model was used to assess two subpopulations of mrET - those eligible and those ineligible for neurosurgery - in the context specific to England and its healthcare system. For those eligible for neurosurgery, MRgFUS was compared to DBS, the current standard treatment. For those ineligible for neurosurgery, MRgFUS was compared to treatment with medication alone. The model calculated the Incremental cost-effectiveness ratio (ICER) with appropriate sensitivity and scenario analyses. RESULTS For those eligible for neurosurgery: In the model base case, the MRgFUS was economically dominant compared to DBS; MRgFUS was less costly (£19,779 vs £62,348) and more effective generating 0.03 additional quality-adjusted life-years (QALYs) per patient (3.71 vs 3.68) over the 5-year time horizon.For those ineligible for neurosurgery: In the model base case, MRgFUS cost over £16,000 per patient more than medication alone (£19,779 vs £62,348) but yielded 0.77 additional QALYs per patient(3.71 vs 2.95), producing an incremental cost-effectiveness ratio (ICER) of £20,851 per QALY. This ICER of £20,851 per QALY falls within the National Institute for Clinical Excellence's (NICE) willingness to pay threshold (WTP) of 20,000-30,000 demonstrating the cost-effectiveness profile of MRgFUS. CONCLUSION This study demonstrates the favourable cost-effectiveness profile of MRgFUS for the treatment of mrET in England; in both patients suitable and not suitable for neurosurgery. ADVANCES IN KNOWLEDGE The introduction of MRgFUS as a widely available ET treatment in UK is currently undergoing the necessary stages of regulatory approval. As the first European study, these favourable cost-effectiveness outcomes (notably the model base case ICER falling within NICE's WTP) can provide a basis for future commissioning of brain MRgFUS treatments in the UK, Europe and globally.
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Affiliation(s)
| | - Anne Meiwald
- UK Aquarius Population Health Limited, London, United Kingdom
| | - Peter Bain
- Division of Brain Sciences, Imperial College London, London, United Kingdom
| | - Neekhil Patel
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Dipankar Nandi
- Department of Neurosciences, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Brynmor Jones
- Department of Radiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Georgie Weston
- UK Aquarius Population Health Limited, London, United Kingdom
| | | | - Wladyslaw Gedroyc
- Department of Radiology, Imperial College Healthcare NHS Trust, London, United Kingdom
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5
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Yamamoto K, Sarica C, Loh A, Vetkas A, Samuel N, Milano V, Zemmar A, Germann J, Cheyuo C, Boutet A, Elias GJ, Ito H, Taira T, Lozano AM. Magnetic resonance-guided focused ultrasound for the treatment of tremor. Expert Rev Neurother 2022; 22:849-861. [PMID: 36469578 DOI: 10.1080/14737175.2022.2147826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Magnetic resonance-guided focused ultrasound (MRgFUS) is an emerging treatment for tremor and other movement disorders. An incisionless therapy, it is becoming increasingly common worldwide. However, given MRgFUS' relative novelty, there remain limited data on its benefits and adverse effects. AREAS COVERED We review the current state of evidence of MRgFUS for tremor, highlight its challenges, and discuss future perspectives. EXPERT OPINION Essential tremor (ET) has been the major indication for MRgFUS since a milestone randomized controlled trial (RCT) in 2016, with substantial evidence attesting to the efficacy and acceptable safety profile of this treatment. Patients with other tremor etiologies are also being treated with MRgFUS, with studies - including an RCT - suggesting parkinsonian tremor in particular responds well to this intervention. Additionally, targets other than the ventral intermediate nucleus, such as the subthalamic nucleus and internal segment of the globus pallidus, have been reported to improve parkinsonian symptoms beyond tremor, including rigidity and bradykinesia. Although MRgFUS is encumbered by certain unique technical challenges, it nevertheless offers significant advantages compared to alternative neurosurgical interventions for tremor. The fast-growing interest in this treatment modality will likely lead to further scientific and technological advancements that could optimize and expand its therapeutic potential.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Artur Vetkas
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Department of Neurosurgery, School of Medicine, University of Tartu, Estonia
| | - Nardin Samuel
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Vanessa Milano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, School of Medicine, KY, USA.,Department of Neurosurgery, Henan University People's Hospital, Henan University School of Medicine, China
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Gavin Jb Elias
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Hisashi Ito
- Department of Neurology, Shonantobu General Hospital, Japan.,Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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6
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Bismuth M, Katz S, Mano T, Aronovich R, Hershkovitz D, Exner AA, Ilovitsh T. Low frequency nanobubble-enhanced ultrasound mechanotherapy for noninvasive cancer surgery. NANOSCALE 2022; 14:13614-13627. [PMID: 36070492 DOI: 10.1039/d2nr01367c] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Scaling down the size of microbubble contrast agents to the nanometer level holds the promise for noninvasive cancer therapy. However, the small size of nanobubbles limits the obtained bioeffects as a result of ultrasound cavitation, when operating near the nanobubble resonance frequency. Here we show that coupled with low energy insonation at a frequency of 80 kHz, well below the resonance frequency of these agents, nanobubbles serve as noninvasive therapeutic warheads that trigger potent mechanical effects in tumors following a systemic injection. We demonstrate these capabilities in tissue mimicking phantoms, where a comparison of the acoustic response of micro- and nano-bubbles after insonation at a frequency of 250 or 80 kHz revealed that higher pressures were needed to implode the nanobubbles compared to microbubbles. Complete nanobubble destruction was achieved at a mechanical index of 2.6 for the 250 kHz insonation vs. 1.2 for the 80 kHz frequency. Thus, the 80 kHz insonation complies with safety regulations that recommend operation below a mechanical index of 1.9. In vitro in breast cancer tumor cells, the cell viability was reduced to 17.3 ± 1.7% of live cells. In vivo, in a breast cancer tumor mouse model, nanobubble tumor distribution and accumulation were evaluated by high frequency ultrasound imaging. Finally, nanobubble-mediated low frequency insonation of breast cancer tumors resulted in effective mechanical tumor ablation and tumor tissue fractionation. This approach provides a unique theranostic platform for safe, noninvasive and low energy tumor mechanotherapy.
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Affiliation(s)
- Mike Bismuth
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel.
| | - Sharon Katz
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel.
- The Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Tamar Mano
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel.
| | - Ramona Aronovich
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel.
| | - Dov Hershkovitz
- Department of Pathology, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997800, Israel
| | - Agata A Exner
- Departments of Radiology and Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Tali Ilovitsh
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv 6997801, Israel.
- The Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
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7
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4D printing of soft orthoses for tremor suppression. Biodes Manuf 2022. [DOI: 10.1007/s42242-022-00199-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AbstractTremor is an involuntary and oscillatory movement disorder that makes daily activities difficult for affected patients. Hand tremor-suppression orthoses are noninvasive, wearable devices designed to mitigate tremors. Various studies have shown that these devices are effective, economical, and safe; however, they have drawbacks such as large weight, awkward shape, and rigid parts. This study investigates different types of tremor-suppression orthoses and discusses their efficiency, mechanism, benefits, and disadvantages. First, various orthoses (with passive, semi-active, and active mechanisms) are described in detail. Next, we look at how additive manufacturing (AM) has progressed recently in making sensors and actuators for application in tremor orthoses. Then, the materials used in AM are further analyzed. It is found that traditional manufacturing problems can be solved with the help of AM techniques, like making orthoses that are affordable, lighter, and more customizable. Another concept being discussed is using smart materials and AM methods, such as four-dimensional (4D) printing, to make orthoses that are more comfortable and efficient.
Graphic abstract
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8
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Titova NV, Katunina EA, Tairova RT, Sen'ko IV, Dzhafarov VM, Malykhina EA. [The problem of pharmacoresistant tremor in Parkinson's disease and essential tremor]. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:24-30. [PMID: 36279225 DOI: 10.17116/jnevro202212210124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
MR-guided focused ultrasound (MRg-FUS) is a new noninvasive method for the treatment of contralateral disabling and pharmacoresistant tremor. Clinical studies have confirmed the high efficacy and safety of using MRg-FUS in patients with essential tremor and Parkinson's disease, in short and long-term studies. Advantages of this method in comparison with currently used invasive and noninvasive technics, potential brain target areas, the possibility of bilateral intervention, indications and contraindications are discussed.
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Affiliation(s)
- N V Titova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E A Katunina
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - R T Tairova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Sen'ko
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - V M Dzhafarov
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - E A Malykhina
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
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9
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Alshenqiti U, Alzalabani Y, Siddiqui K, Alfaisal S, Albadrani M. Focused ultrasound and deep brain stimulation for Parkinsonism – Review of literature to investigate tradeoff between safety and efficacy. SAUDI JOURNAL FOR HEALTH SCIENCES 2022. [DOI: 10.4103/sjhs.sjhs_86_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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10
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Abstract
Essential tremor (ET) is one of the most common movement disorders, with a reported >60 million affected individuals worldwide. The definition and underlying pathophysiology of ET are contentious. Patients present primarily with motor features such as postural and action tremors, but may also have other non-motor features, including cognitive impairment and neuropsychiatric symptoms. Genetics account for most of the ET risk but environmental factors may also be involved. However, the variable penetrance and challenges in validating data make gene-environment analysis difficult. Structural changes in cerebellar Purkinje cells and neighbouring neuronal populations have been observed in post-mortem studies, and other studies have found GABAergic dysfunction and dysregulation of the cerebellar-thalamic-cortical circuitry. Commonly prescribed medications include propranolol and primidone. Deep brain stimulation and ultrasound thalamotomy are surgical options in patients with medically intractable ET. Further research in post-mortem studies, and animal and cell-based models may help identify new pathophysiological clues and therapeutic targets and, together with advances in omics and machine learning, may facilitate the development of precision medicine for patients with ET.
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11
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Zhang M, Rodrigues A, Zhou Q, Li G. Focused ultrasound: growth potential and future directions in neurosurgery. J Neurooncol 2021; 156:23-32. [PMID: 34410576 DOI: 10.1007/s11060-021-03820-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/31/2021] [Indexed: 12/18/2022]
Abstract
Over the past two decades, vast improvements in focused ultrasound (FUS) technology have made the therapy an exciting addition to the neurosurgical armamentarium. In this time period, FUS has gained US Food and Drug Administration (FDA) approval for the treatment of two neurological disorders, and ongoing efforts seek to expand the lesion profile that is amenable to ultrasonic intervention. In the following review, we highlight future applications for FUS therapy and compare its potential role against established technologies, including deep brain stimulation and stereotactic radiosurgery. Particular attention is paid to tissue ablation, blood-brain-barrier opening, and gene therapy. We also address technical and infrastructural challenges involved with FUS use and summarize the hurdles that must be overcome before FUS becomes widely accepted in the neurosurgical community.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA. .,Center for Academic Medicine, Neurosurgery, Stanford University School of Medicine, MC 5327, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Adrian Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.,Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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12
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Meng Y, Jones RM, Davidson B, Huang Y, Pople CB, Surendrakumar S, Hamani C, Hynynen K, Lipsman N. Technical Principles and Clinical Workflow of Transcranial MR-Guided Focused Ultrasound. Stereotact Funct Neurosurg 2020; 99:329-342. [PMID: 33302282 DOI: 10.1159/000512111] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Abstract
Transcranial MR-guided focused ultrasound (MRgFUS) is a rapidly developing technology in neuroscience for manipulating brain structure and function without open surgery. The effectiveness of transcranial MRgFUS for thermoablation is well established, and the technique is actively employed worldwide for movement disorders including essential tremor. A growing number of centers are also investigating the potential of microbubble-mediated focused ultrasound-induced opening of the blood-brain barrier (BBB) for targeted drug delivery to the brain. Here, we provide a technical overview of the principles, clinical workflow, and operator considerations of transcranial MRgFUS procedures for both thermoablation and BBB opening.
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Affiliation(s)
- Ying Meng
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ryan M Jones
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Davidson
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yuexi Huang
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B Pople
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | | | - Clement Hamani
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada, .,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada,
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13
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Allen SP, Prada F, Xu Z, Gatesman J, Feng X, Sporkin H, Gilbo Y, DeCleene S, Pauly KB, Meyer CH. A preclinical study of diffusion-weighted MRI contrast as an early indicator of thermal ablation. Magn Reson Med 2020; 85:2145-2159. [PMID: 33174639 DOI: 10.1002/mrm.28537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 08/28/2020] [Accepted: 09/09/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Intraoperative T2 -weighted (T2-w) imaging unreliably captures image contrast specific to thermal ablation after transcranial MR-guided focused ultrasound surgery, impeding dynamic imaging feedback. Using a porcine thalamotomy model, we test the unproven hypothesis that intraoperative DWI can improve dynamic feedback by detecting lesioning within 30 minutes of transcranial MR-guided focused ultrasound surgery. METHODS Twenty-five thermal lesions were formed in six porcine models using a clinical transcranial MR-guided focused ultrasound surgery system. A novel diffusion-weighted pulse sequence monitored the formation of T2-w and diffusion-weighted lesion contrast after ablation. Using postoperative T2-w contrast to indicate lesioning, apparent intraoperative image contrasts and diffusion coefficients at each lesion site were computed as a function of time after ablation, observed peak temperature, and observed thermal dose. Lesion sizes segmented from imaging and thermometry were compared. Image reviewers estimated the time to emergence of lesion contrast. Intraoperative image contrasts were analyzed using receiver operator curves. RESULTS On average, the apparent diffusion coefficient at lesioned sites decreased within 5 minutes after ablation relative to control sites. In-plane lesion areas on intraoperative DWI varied from postoperative T2-w MRI and MR thermometry by 9.6 ± 9.7 mm2 and - 4.0 ± 7.1 mm2 , respectively. The 0.25, 0.5, and 0.75 quantiles of the earliest times of observed T2-w and diffusion-weighted lesion contrast were 10.7, 21.0, and 27.8 minutes and 3.7, 8.6, and 11.8 minutes, respectively. The T2-w and diffusion-weighted contrasts and apparent diffusion coefficient values produced areas under the receiver operator curve of 0.66, 0.80, and 0.74, respectively. CONCLUSION Intraoperative DWI can detect MR-guided focused ultrasound surgery lesion formation in the brain within several minutes after treatment.
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Affiliation(s)
- Steven P Allen
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jeremy Gatesman
- Center for Comparative Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Xue Feng
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Helen Sporkin
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Yekaterina Gilbo
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Sydney DeCleene
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Kim Butts Pauly
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Craig H Meyer
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA.,Department of Radiology, University of Virginia, Charlottesville, Virginia, USA
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14
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Meng Y, Hynynen K, Lipsman N. Applications of focused ultrasound in the brain: from thermoablation to drug delivery. Nat Rev Neurol 2020; 17:7-22. [PMID: 33106619 DOI: 10.1038/s41582-020-00418-z] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
Focused ultrasound (FUS) is a disruptive medical technology, and its implementation in the clinic represents the culmination of decades of research. Lying at the convergence of physics, engineering, imaging, biology and neuroscience, FUS offers the ability to non-invasively and precisely intervene in key circuits that drive common and challenging brain conditions. The actions of FUS in the brain take many forms, ranging from transient blood-brain barrier opening and neuromodulation to permanent thermoablation. Over the past 5 years, we have seen a dramatic expansion of indications for and experience with FUS in humans, with a resultant exponential increase in academic and public interest in the technology. Applications now span the clinical spectrum in neurological and psychiatric diseases, with insights still emerging from preclinical models and human trials. In this Review, we provide a comprehensive overview of therapeutic ultrasound and its current and emerging indications in the brain. We examine the potential impact of FUS on the landscape of brain therapies as well as the challenges facing further advancement and broader adoption of this promising minimally invasive therapeutic alternative.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Harquail Centre for Neuromodulation, Toronto, ON, Canada.,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Biophysics and Institute of Biomaterials & Biomedical Engineering (IBBME), University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Harquail Centre for Neuromodulation, Toronto, ON, Canada. .,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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15
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Magnetic resonance-guided focused ultrasound capsulotomy for refractory obsessive compulsive disorder and major depressive disorder: clinical and imaging results from two phase I trials. Mol Psychiatry 2020; 25:1946-1957. [PMID: 32404942 DOI: 10.1038/s41380-020-0737-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022]
Abstract
Obsessive compulsive disorder (OCD) and major depressive disorder (MDD) are common, often refractory, neuropsychiatric conditions for which new treatment approaches are urgently needed. Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel surgical technique permitting incisionless ablative neurosurgery. We examined the safety profile, clinical response, and imaging correlates of MRgFUS bilateral anterior capsulotomy in patients with refractory obsessive compulsive disorder (OCD, N = 6) and major depressive disorder (MDD, n = 6). There were no serious adverse events. Nonserious adverse events included headaches and pin-site swelling in 7/12 patients. The response rate was 4/6 and 2/6 in the OCD and MDD cohorts respectively. To delineate the white-matter tracts impacted by capsulotomy, a normative diffusion MRI-based structural connectome was used, revealing tracts terminating primarily in the frontal pole, medial thalamus, striatum, and medial-temporal lobe. Positron emission tomography (PET) analysis (nine subjects) revealed widespread decreases in metabolism bilaterally in the cerebral hemispheres at 6 months post treatment, as well as in the right hippocampus, amygdala, and putamen. A pretreatment seed-to-voxel resting-state functional magnetic resonance imaging (rs-fMRI) analysis (12 subjects) revealed three voxel clusters significantly associated with eventual clinical response. MRgFUS capsulotomy appears to be safe, well tolerated, and according to these initial results, may be an important treatment option for patients with refractory OCD and MDD. MRgFUS capsulotomy results in both targeted and widespread changes in neural activity, and neuroimaging may hold potential for the prediction of outcome.
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16
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Meng Y, Pople CB, Kalia SK, Kalia LV, Davidson B, Bigioni L, Li DZ, Suppiah S, Mithani K, Scantlebury N, Schwartz ML, Hamani C, Lipsman N. Cost-effectiveness analysis of MR-guided focused ultrasound thalamotomy for tremor-dominant Parkinson's disease. J Neurosurg 2020; 135:273-278. [PMID: 32764177 DOI: 10.3171/2020.5.jns20692] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The development of transcranial MR-guided focused ultrasound (MRgFUS) has revitalized the practice of lesioning procedures in functional neurosurgery. Previous health economic analysis found MRgFUS thalamotomy to be a cost-effective treatment for patients with essential tremor, supporting its reimbursement. With the publication of level I evidence in support of MRgFUS thalamotomy for patients with tremor-dominant Parkinson's disease (TDPD), the authors performed a health economic comparison between MRgFUS, deep brain stimulation (DBS), and medical therapy. METHODS The authors used a decision tree model with rollback analysis and one-factor sensitivity analysis. Literature searches of MRgFUS thalamotomy and unilateral DBS of the ventrointermediate nucleus of the thalamus for TDPD were performed to determine the utility and probabilities for the model. Costs in Canadian dollars (CAD) were derived from the Schedule of Benefits and Fees in Ontario, Canada, and expert opinion on usage. RESULTS MRgFUS was associated with an expected cost of $14,831 CAD. Adding MRgFUS to continued medical therapy resulted in an incremental cost-effectiveness ratio of $30,078 per quality-adjusted life year (QALY), which remained cost-effective under various scenarios in the sensitivity analysis. Comparing DBS to MRgFUS, while DBS did not achieve the willingness-to-pay threshold ($56,503 per QALY) in the base case scenario, it did so under several scenarios in the sensitivity analysis. CONCLUSIONS MRgFUS thalamotomy is a cost-effective treatment for patients with TDPD, particularly over continued medical therapy. While MRgFUS remains competitive with DBS, the cost-effectiveness advantage is less substantial. These results will help inform the integration of this technology in the healthcare system.
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Affiliation(s)
- Ying Meng
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Christopher B Pople
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Suneil K Kalia
- 3Division of Neurosurgery, Toronto Western Hospital, University Health Network
- 4Krembil Research Institute, Toronto Western Hospital, University Health Network
| | - Lorraine V Kalia
- 4Krembil Research Institute, Toronto Western Hospital, University Health Network
- 5Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network; and
- 6Tanz Centre for Research in Neurodegenerative Diseases, and
- 7Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada
| | - Benjamin Davidson
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Luca Bigioni
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Daniel Zhengze Li
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Suganth Suppiah
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
| | - Karim Mithani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | | | | | - Clement Hamani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
| | - Nir Lipsman
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation, Sunnybrook Research Institute
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17
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Abstract
Established medications that improve tremor include beta-adrenergic antagonists, primidone, topiramate, and ethanol. Less consistent efficacy is reported with many other medications, usually antiepileptic drugs. A number of investigational medications, including T-type calcium channel blockers and allosteric gamma-aminobutyric acid-A modulators, are being developed for tremor. Deep brain stimulation techniques continues to be refined and focused ultrasound thalamotomy now offers an incisionless surgical option. Finally a number of peripheral electrical and mechanical devices are under development for tremor.
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Affiliation(s)
- William George Ondo
- Movement Disorders-Methodist Neurological Institute, Weill Cornel Medical School, 6560 Fannin Suite 1002, Houston, TX 77025, USA.
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18
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Fernandez-Garcia C, Alonso-Frech F, Monje MHG, Matias-Guiu J. Role of deep brain stimulation therapy in the magnetic resonance-guided high-frequency focused ultrasound era: current situation and future prospects. Expert Rev Neurother 2019; 20:7-21. [PMID: 31623494 DOI: 10.1080/14737175.2020.1677465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Deep brain stimulation (DBS) is a well-established treatment of movement disorders; but recently there has been an increasing trend toward the ablative procedure magnetic resonance-guided focused ultrasound (MRgFU). DBS is an efficient neuromodulatory technique but associated with surgical complications. MRIgFUS is an incision-free method that allows thermal lesioning, with fewer surgical complications but irreversible effects.Areas covered: We look at current and prospective aspects of both techniques. In DBS, appropriate patient selection, improvement in surgical expertise, target accuracy (preoperative and intraoperative imaging), neurophysiological recordings, and novel segmented leads need to be considered. However, increased number of older patients with higher comorbidities and risk of DBS complications (mainly intracranial hemorrhage, but also infections, hardware complications) make them not eligible for surgery. With MRgFUS, hemorrhage risks are virtually nonexistent, infection or hardware malfunction are eliminated, while irreversible side effects can appear.Expert commentary: Comparison of the efficacy and risks associated with these techniques, in combination with a growing aged population in developed countries with higher comorbidities and a preference for less invasive treatments, necessitates a review of the indications for movement disorders and the most appropriate treatment modalities.
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Affiliation(s)
- C Fernandez-Garcia
- Department of Neurosurgery, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Madrid, Spain.,Medicine Department, Universidad Complutense, Madrid, Spain
| | - F Alonso-Frech
- Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain.,HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - M H G Monje
- HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - J Matias-Guiu
- Medicine Department, Universidad Complutense, Madrid, Spain.,Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain
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