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Gironell A, Marín-Lahoz J, Póveda S. Essential Tremor: Update of Therapeutic Strategies. Med Clin (Barc) 2024; 162:599-605. [PMID: 38553256 DOI: 10.1016/j.medcli.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 06/18/2024]
Abstract
In the last decades there has been progress in the treatment of essential tremor (TE) especially in the surgical field and to a lesser extent in the pharmacological field. We carry out a review of the currently available treatments. The first intervention is the use of non-pharmacological and non-surgical strategies (general advice, occupational therapy, speech therapy, psychotherapy). With discrete advances, the pharmacological treatment is not very satisfactory. Only 30-60% of patients have a positive response, and in these the anti-tremor effectiveness is 40-60%. The first-line drugs are still propranolol and primidone. In cases with severe tremor we will consider a surgical option, the method of choice being thalamotomy using high-intensity focused ultrasound. In the future we must continue to study the pathophysiology of TE, develop drugs specifically designed for TE and improve the technology of available invasive techniques.
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Affiliation(s)
- Alexandre Gironell
- Unidad de Trastornos del Movimiento, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | - Juan Marín-Lahoz
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Grupo de Neurociencias, IIS Aragón, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
| | - Santiago Póveda
- Unidad de Trastornos del Movimiento, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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2
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Miguel-Puga A, Villafuerte G, Treviño M, Ortega-Robles E, Arias-Carrión O. Effect of Propranolol on Motor Cortex Excitability in Essential Tremor: An Exploratory Study. Tremor Other Hyperkinet Mov (N Y) 2024; 14:1. [PMID: 38189055 PMCID: PMC10768567 DOI: 10.5334/tohm.829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024] Open
Abstract
Background Essential tremor, the world's most prevalent movement disorder, lacks a clear understanding of its pathophysiology. Propranolol, a non-specific beta-blocker capable of crossing the blood-brain barrier, is a primary choice for essential tremor treatment. While its tremor-reducing effects are generally attributed to peripheral actions, various uses hint at central adrenergic effects. Nevertheless, propranolol's precise impact on the central nervous system in essential tremor subjects remains unexplored. Methods In this study, we employed transcranial magnetic stimulation to assess the influence of propranolol on the excitability of the primary motor cortex (M1) in patients with essential tremor, compared to an age- and sex-matched control group. Cortical excitability parameters were measured following placebo and propranolol administration, encompassing resting and active motor thresholds, motor evoked potential characteristics, cortical silent period, and the input/output curve. Results Distinct effects were observed across the two cortical hemispheres. Essential tremor patients displayed inhibition of the left M1 cortex and heightened excitability in the right M1 cortex four hours after propranolol administration, but not following placebo. Conclusions These findings suggest potential differential noradrenergic excitatory and inhibitory modulation. However, comprehensive understanding necessitates further investigations, including left-handed participants and more diverse essential tremor subpopulations. This study underscores the need for continued exploration to unravel propranolol's complex effects on motor cortex excitability in essential tremor.
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Affiliation(s)
- Adán Miguel-Puga
- Unidad de Trastornos del Movimiento y Sueño (TMS), Hospital General Dr. Manuel Gea González. Ciudad de México, 14080 México, MX
| | - Gabriel Villafuerte
- Unidad de Trastornos del Movimiento y Sueño (TMS), Hospital General Dr. Manuel Gea González. Ciudad de México, 14080 México, MX
| | - Mario Treviño
- Laboratorio de Plasticidad Cortical y Aprendizaje Perceptual, Instituto de Neurociencias, Universidad de Guadalajara, Guadalajara, 44130 México, MX
| | - Emmanuel Ortega-Robles
- Unidad de Trastornos del Movimiento y Sueño (TMS), Hospital General Dr. Manuel Gea González. Ciudad de México, 14080 México, MX
| | - Oscar Arias-Carrión
- Unidad de Trastornos del Movimiento y Sueño (TMS), Hospital General Dr. Manuel Gea González. Ciudad de México, 14080 México, MX
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Antonazzo IC, Rozza D, Conti S, Fornari C, Cortesi PA, Eteve-Pitsaer C, Paris C, Gantzer L, Valentine D, Mantovani LG, Mazzaglia G. Treatment patterns in essential tremor: Real-world evidence from a United Kingdom and France primary care database. Eur J Neurol 2024; 31:e16064. [PMID: 37738526 DOI: 10.1111/ene.16064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND PURPOSE Essential tremor (ET) is one of the most common neurological disorders, but information on treatment pattern is still scant. The aim of this study was to describe the demographic and clinical characteristics, treatment patterns, and determinants of drug use in patients with newly diagnosed ET in France and the United Kingdom. METHODS Incident cases of ET diagnosed between January 1, 2015 and December 31, 2018 with 2 years of follow-up were identified by using The Health Improvement Network (THIN®) general practice database. During the follow-up, we assessed the daily prevalence of use and potential switches from first-line to second-line treatment or other lines of treatment. Logistic regression models were conducted to assess the effect of demographic and clinical characteristics on the likelihood of receiving ET treatment. RESULTS A total of 2957 and 3249 patients were selected in the United Kingdom and France, respectively. Among ET patients, drug use increased from 12 months to 1 month prior the date of index diagnosis (ID). After ID, nearly 40% of patients received at least one ET treatment, but during follow-up drug use decreased and at the end of the follow-up approximately 20% of patients were still on treatment. Among treated patients, ≤10% maintained the same treatment throughout the entire follow-up, nearly 20% switched, and 40%-75% interrupted any treatment. Results from the multivariate analysis revealed that, both in France and the United Kingdom, patients receiving multiple concomitant therapies and affected by psychiatric conditions were more likely to receive an ET medication. CONCLUSION This study shows that ET is an undertreated disease with a lower-than-expected number of patients receiving and maintaining pharmacological treatment. Misclassification of ET diagnosis should be acknowledged; thus, results require cautious interpretation.
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Affiliation(s)
- Ippazio Cosimo Antonazzo
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
- Unit of Medical Statistics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Davide Rozza
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Sara Conti
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Carla Fornari
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Paolo Angelo Cortesi
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | | | - Claire Paris
- Cegedim Health data, Boulogne-Billancourt, France
| | | | | | | | - Giampiero Mazzaglia
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
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Triguero-Cueva L, Marín-Romero B, Madrid-Navarro CJ, Pérez-Navarro MJ, Iáñez-Velasco B, Mínguez-Castellanos A, Katati MJ, Escamilla-Sevilla F. Neuropsychological assessment protocol in an ongoing randomized controlled trial on posterior subthalamic area vs. ventral intermediate nucleus deep brain stimulation for essential tremor. Front Neurol 2023; 14:1222592. [PMID: 38020655 PMCID: PMC10643533 DOI: 10.3389/fneur.2023.1222592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Patients with essential tremor (ET) may experience cognitive-affective impairment. Deep brain stimulation (DBS) of different targets, such as the ventral intermediate nucleus (VIM) of the thalamus or the posterior subthalamic area (PSA), has been shown to be beneficial for refractory ET. However, there is little evidence regarding the possible neuropsychological effects of PSA-DBS on patients with ET, and there are few studies comparing it with VIM-DBS in this population.In this study, we aim to present the evaluation protocol and neuropsychological battery as used in an ongoing trial of DBS for ET comparing the already mentioned targets. Methods As part of a randomized, double-blind, crossover clinical trial comparing the effectiveness and safety of PSA-DBS vs. VIM-DBS, 11 patients with refractory ET will undergo a multi-domain neuropsychological battery assessment. This will include a pre-/post-implantation assessment (3 months after the stimulation of each target and 6 months after an open stage of DBS on the most optimal target). Conclusion Evidence on the neuropsychological effects of DBS in patients with refractory ET is very scarce, particularly in lesser-explored targets such as PSA. This study could contribute significantly in this field, particularly on pre-procedure safety analysis for tailored patient/technique selection, and to complete the safety analysis of the procedure. Moreover, if proven useful, this proposed neuropsychological assessment protocol could be extensible to other surgical therapies for ET.
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Affiliation(s)
- Lucía Triguero-Cueva
- Department of Neurology Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
| | - Bartolomé Marín-Romero
- Department of Neuropsychology Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Carlos Javier Madrid-Navarro
- Department of Neurology Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
| | | | | | - Adolfo Mínguez-Castellanos
- Department of Neurology Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
| | - Majed Jouma Katati
- Department of Neurosurgery Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Escamilla-Sevilla
- Department of Neurology Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
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Pae C, Kim MJ, Chang WS, Jung HH, Chang KW, Eo J, Park HJ, Chang JW. Differences in intrinsic functional networks in patients with essential tremor who had good and poor long-term responses after thalamotomy performed using MR-guided ultrasound. J Neurosurg 2023; 138:318-328. [PMID: 35901685 DOI: 10.3171/2022.5.jns22324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Thalamotomy at the nucleus ventralis intermedius using MR-guided focused ultrasound has been an effective treatment method for essential tremor (ET). However, this is not true for all cases, even for successful ablation. How the brain differs in patients with ET between those with long-term good and poor outcomes is not clear. To analyze the functional connectivity difference between patients in whom thalamotomy was effective and those in whom thalamotomy was ineffective and its prognostic role in ET treatment, the authors evaluated preoperative resting-state functional MRI in thalamotomy-treated patients. METHODS Preoperative resting-state functional MRI data in 85 patients with ET, who were experiencing tremor relief at the time of treatment and were followed up for a minimum of 6 months after the procedure, were collected for the study. The authors conducted a graph independent component analysis of the functional connectivity matrices of tremor-related networks. The patients were divided into thalamotomy-effective and thalamotomy-ineffective groups (thalamotomy-effective group, ≥ 50% motor symptom reduction; thalamotomy-ineffective group, < 50% motor symptom reduction at 6 months after treatment) and the authors compared network components between groups. RESULTS Seventy-two (84.7%) of the 85 patients showed ≥ 50% tremor reduction from baseline at 6 months after thalamotomy. The network analysis shows significant suppression of functional network components with connections between the areas of the cerebellum and the basal ganglia and thalamus, but enhancement of those between the premotor cortex and supplementary motor area in the noneffective group compared to the effective group. CONCLUSIONS The present study demonstrates that patients in the noneffective group have suppressed functional subnetworks in the cerebellum and subcortex regions and have enhanced functional subnetworks among motor-sensory cortical networks compared to the thalamotomy-effective group. Therefore, the authors suggest that the functional connectivity pattern might be a possible predictive factor for outcomes of MR-guided focused ultrasound thalamotomy.
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Affiliation(s)
- Chongwon Pae
- 1Center for Systems and Translational Brain Sciences, Institute of Human Complexity and Systems Science, Yonsei University, Seoul.,2Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul.,8Department of Psychiatry, Bundang CHA Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Myung Ji Kim
- 3Department of Neurosurgery, Korea University College of Medicine, Korea University Medical Center, Ansan Hospital, Gyeonggi-do
| | - Won Seok Chang
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul.,5Center for Innovative Functional Neurosurgery, Brain Research Institute, Seoul
| | - Hyun Ho Jung
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul.,5Center for Innovative Functional Neurosurgery, Brain Research Institute, Seoul
| | - Kyung Won Chang
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul
| | - Jinseok Eo
- 1Center for Systems and Translational Brain Sciences, Institute of Human Complexity and Systems Science, Yonsei University, Seoul.,2Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul.,6Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul
| | - Hae-Jeong Park
- 1Center for Systems and Translational Brain Sciences, Institute of Human Complexity and Systems Science, Yonsei University, Seoul.,2Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul.,6Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul.,7Department of Cognitive Science, Yonsei University, Seoul; and
| | - Jin Woo Chang
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul.,5Center for Innovative Functional Neurosurgery, Brain Research Institute, Seoul
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Delgado N, Berry DS, Hernandez DI, Louis ED. Prospective, longitudinal analysis of medication use in a cohort of elderly essential tremor cases. J Neurol Sci 2022; 442:120387. [PMID: 36041330 DOI: 10.1016/j.jns.2022.120387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/01/2022] [Accepted: 08/17/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND There are no prospective, longitudinal studies investigating patterns of medication use among essential tremor (ET) patients. Our goal was to fill this knowledge gap. We also had a unique opportunity to examine medication use patterns primarily among elders with longstanding ET. We hypothesized that by the time ET patients reach advanced ages, medication changes would be uncommon - that is, they may have reached some kind of equipoise. METHODS A prospective, longitudinal cohort of ET cases was evaluated across three time points. Cases were not ascertained from a treatment setting, thereby removing important selection biases. Each reported current medications and dosages of each. RESULTS There were 144 cases (mean baseline age = 76.1 ± 9.4 years). The mean observation period = 2.9 ± 0.2 years. Primidone and propranolol were the most commonly used medications, although almost one-half of cases (44.4%) reported using neither during this period. A third of primidone users (33.3%) and a quarter of propranolol users (24.6%) reported changes in use vs. nonuse during the observation period. The majority of our cases made some change in their daily medication dosage during the course of the study - 73.3% of primidone users and 57.9% of propranolol users. CONCLUSION In this prospective, longitudinal study, use vs. nonuse and daily dosage of both primidone and propranolol fluctuated across time for a sizable proportion of ET cases. Even among elders with chronic, longstanding ET, there is considerable ongoing medication adjustment, underscoring the need to improve the medication situation for ET patients.
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Affiliation(s)
- Nikki Delgado
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Diane S Berry
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Daniella Iglesias Hernandez
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Elan D Louis
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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Farhani G, Zhou Y, Jenkins ME, Naish MD, Trejos AL. Using Deep Learning for Task and Tremor Type Classification in People with Parkinson's Disease. SENSORS (BASEL, SWITZERLAND) 2022; 22:7322. [PMID: 36236422 PMCID: PMC9570986 DOI: 10.3390/s22197322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
Hand tremor is one of the dominating symptoms of Parkinson's disease (PD), which significantly limits activities of daily living. Along with medications, wearable devices have been proposed to suppress tremor. However, suppressing tremor without interfering with voluntary motion remains challenging and improvements are needed. The main goal of this work was to design algorithms for the automatic identification of the tremor type and voluntary motions, using only surface electromyography (sEMG) data. Towards this goal, a bidirectional long short-term memory (BiLSTM) algorithm was implemented that uses sEMG data to identify the motion and tremor type of people living with PD when performing a task. Moreover, in order to automate the training process, hyperparamter selection was performed using a regularized evolutionary algorithm. The results show that the accuracy of task classification among 15 people living with PD was 84±8%, and the accuracy of tremor classification was 88±5%. Both models performed significantly above chance levels (20% and 33% for task and tremor classification, respectively). Thus, it was concluded that the trained models, based on using purely sEMG signals, could successfully identify the task and tremor types.
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Affiliation(s)
- Ghazal Farhani
- Department of Electrical and Computer Engineering, Western University, London, ON N6A 5B9, Canada
| | - Yue Zhou
- School of Biomedical Engineering, Western University, London, ON N6A 5B9, Canada
| | - Mary E. Jenkins
- Movement Disorders Program, Clinical Neurological Sciences, Western University, London, ON N6A 3K7, Canada
| | - Michael D. Naish
- Department of Electrical and Computer Engineering, Western University, London, ON N6A 5B9, Canada
- School of Biomedical Engineering, Western University, London, ON N6A 5B9, Canada
- Department of Mechanical and Materials Engineering, Western University, London, ON N6A 5B9, Canada
| | - Ana Luisa Trejos
- Department of Electrical and Computer Engineering, Western University, London, ON N6A 5B9, Canada
- School of Biomedical Engineering, Western University, London, ON N6A 5B9, Canada
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The Pharmacotherapeutic Landscape for Essential Tremor: Quantifying the Level of Unmet Need From a Patient and Epidemiologic Perspective. Clin Neuropharmacol 2022; 45:99-104. [PMID: 35696617 DOI: 10.1097/wnf.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Essential tremor (ET) is one of the most common neurological diseases. Despite this high prevalence, treatment options remain limited. Recent advances in mechanistic research have led to renewed interest in developing newer pharmacotherapeutic agents. Although this is promising, there remains surprisingly little knowledge of the magnitude of the vast ET patient population who would benefit from and/or engage with such agents. This is because the vast bulk of ET patients in the population has milder tremor and does not seek medical care for their tremor. How many of these would be interested in taking a new agent? Hence, the level of unmet need, from the patient perspective and from a public health perspective, is totally unclear. In this article, the author systematically reviews peer-reviewed data on several pertinent questions that relate to this unmet need. The questions are as follows: (1) What proportion of the population of ET cases sees a health care provider for their tremor? (2) What proportion of the ET population has a tremor that is severe enough for them to want to take a medication for their tremor? (3) How do other factors such as age, sex, education, health literacy, and locale affect the receptivity to treatment in ET? (4) What is the patient use of the current ET medications? (5) Is the unmet need greater in some groups of ET cases than others? For each of these questions, available data are carefully reviewed and analyzed, and gaps in knowledge identified for further investigation.
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9
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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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10
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Botulinum Toxin for Essential Tremor and Hands Tremor in the Neurological Diseases: A Meta-Analysis of Randomized Controlled Trials. Toxins (Basel) 2022; 14:toxins14030203. [PMID: 35324700 PMCID: PMC8955110 DOI: 10.3390/toxins14030203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 12/04/2022] Open
Abstract
Tremor is a common movement disorder. Essential tremor (ET) is the most common etiology of tremor, while hands tremor is the most disabling type of tremor. This study aimed to explore the effects of Botulinum toxin (BoNT) on tremor within 6 weeks of treatment, and the muscular weakness adverse effect within 6 weeks specifically in randomized controlled trials. PubMed, Embase, and Cochrane Library databases were searched. Tremor severity and grip strength after BoNT treatment were investigated. BoNT significantly attenuated hand tremor severity in patients with either essential tremor (ET), Parkinson’s disease or multiple sclerosis (Standardized mean difference [SMD] = −0.59, 95% confidence interval [CI], −0.95 to −0.24, p = 0.001, I2 = 46%). Regarding people with ET, BoNT significantly reduced their tremor severity, including hands tremor and head tremor within 6 weeks of treatment (SMD = −0.58, 95% CI, −0.28 to −0.88, p = 0.002, I2 = 0%). Electromyography (EMG) but not anatomical guidance BoNT injection provided significant benefit on the relief of tremor in both conditions. The principal adverse event was weakness, but it did not worse within 6 weeks of BoNT treatment (SMD = −0.35, 95% CI, −0.83 to 0.12, p = 0.07, I2 = 57%), as assessed by the subjective grip strength. In conclusion, BoNT was an effective treatment for the hand tremor and ET, and EMG guidance injection was preferred. In addition, the muscular weakness adverse effect was not significant.
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11
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Bhidayasiri R, Maytharakcheep S, Phumphid S, Maetzler W. Improving functional disability in patients with tremor: A clinical perspective of the efficacies, considerations, and challenges of assistive technology. J Neurol Sci 2022; 435:120197. [DOI: 10.1016/j.jns.2022.120197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
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12
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Gilmour GS, Martino D, Hunka K, Lawrence P, Kiss ZHT, Bruno V. Response to Thalamic Ventralis Intermedius Nucleus Deep Brain Stimulation in Essential Tremor vs. Essential Tremor-Plus. Front Neurol 2021; 12:790027. [PMID: 34912292 PMCID: PMC8666686 DOI: 10.3389/fneur.2021.790027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Essential tremor (ET) is a tremor syndrome characterized by bilateral, upper limb action tremor. Essential tremor-plus (ET-plus) describes ET patients with additional neurologic signs. It is unknown whether there is a difference in response to treatment with ventralis intermedius nucleus deep brain stimulation (VIM DBS) in patients with ET and ET-plus. Due to potential variability in underlying etiology in ET-plus, there is a concern that ET-plus patients may have worse outcomes. The aim of this study was to identify whether patients with ET-plus have worse tremor outcomes after VIM DBS than patients with ET. Methods: This is a retrospective chart and video review evaluating VIM DBS outcomes by comparing changes from baseline in the Fahn-Tolosa-Marin Tremor Rating Scale Part B (FTM-B) for the treated limb between patients with ET and ET-plus at follow-up examinations. Patients were re-classified as having ET or ET-plus using pre-operative examination videos by two independent movement disorders neurologists blinded to patient characteristics. As a secondary outcome, we evaluated for correlations and potential predictors of treatment response. Results: Twenty-six patients were included: 13 with ET, 13 with ET-plus. There were no significant differences in the change in FTM-B scores between the ET and ET-plus patients at each follow-up examination. None of the included patients developed new symptoms compatible with dystonia, parkinsonism or gait disturbances. Conclusions: Patients with ET-plus had tremor improvement from VIM DBS, with no differences when compared to those with ET, without emergence of postoperative neurological issues. Patients with ET-plus should still be considered good candidates for VIM DBS for treatment of tremor.
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Affiliation(s)
- Gabriela S Gilmour
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Karen Hunka
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pia Lawrence
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zelma H T Kiss
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Veronica Bruno
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Kanazono S, Ukai M, Hiramoto A. Abnormal Behavior Episodes Associated With Zonisamide in Three Dogs: A Case Report. Front Vet Sci 2021; 8:763822. [PMID: 34778438 PMCID: PMC8589241 DOI: 10.3389/fvets.2021.763822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Psychiatric adverse effect associated with anti-seizure drugs has been well-recognized in human medicine. This case report describes three dogs with presumptive idiopathic epilepsy presented for abnormal behavior episodes. Abnormal behavior episodes included sudden rage and aggression to the family members, insomnia, restlessness, and/or constant attention-seeking behavior. MRI study and cerebrospinal fluid analysis in two dogs were unremarkable. The abnormal behavior episodes deteriorated along with gradual dose increment of zonisamide and these episodes almost completely disappeared within 5 days after discontinuation of zonisamide. The exact same episodes relapsed within days after re-administration of zonisamide and disappeared again shortly after discontinuation of zonisamide. Dose adjustments of other anti-seizure medications in case 2 did not result in significant changes in these behavior episodes. Although psychiatric adverse effects including aggressive behavior associated with zonisamide are widely recognized in humans, this is the first report in dogs in the clinical setting.
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Affiliation(s)
- Shinichi Kanazono
- Neurology and Neurosurgery Service, Veterinary Specialists & Emergency Center, Kawaguchi, Japan.,Saitama Animal Medical Center, Iruma, Japan
| | - Masayasu Ukai
- Saitama Animal Medical Center, Iruma, Japan.,Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Akira Hiramoto
- Neurology and Neurosurgery Service, Veterinary Specialists & Emergency Center, Kawaguchi, Japan
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14
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Kremer NI, Pauwels RWJ, Pozzi NG, Lange F, Roothans J, Volkmann J, Reich MM. Deep Brain Stimulation for Tremor: Update on Long-Term Outcomes, Target Considerations and Future Directions. J Clin Med 2021; 10:3468. [PMID: 34441763 PMCID: PMC8397098 DOI: 10.3390/jcm10163468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023] Open
Abstract
Deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus is one of the main advanced neurosurgical treatments for drug-resistant tremor. However, not every patient may be eligible for this procedure. Nowadays, various other functional neurosurgical procedures are available. In particular cases, radiofrequency thalamotomy, focused ultrasound and radiosurgery are proven alternatives to DBS. Besides, other DBS targets, such as the posterior subthalamic area (PSA) or the dentato-rubro-thalamic tract (DRT), may be appraised as well. In this review, the clinical characteristics and pathophysiology of tremor syndromes, as well as long-term outcomes of DBS in different targets, will be summarized. The effectiveness and safety of lesioning procedures will be discussed, and an evidence-based clinical treatment approach for patients with drug-resistant tremor will be presented. Lastly, the future directions in the treatment of severe tremor syndromes will be elaborated.
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Affiliation(s)
- Naomi I. Kremer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Rik W. J. Pauwels
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
| | - Nicolò G. Pozzi
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Florian Lange
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Martin M. Reich
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
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15
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Permezel F. Brain MRI-guided focused ultrasound conceptualised as a tool for brain network intervention. J Clin Neurosci 2021; 90:370-379. [PMID: 34275578 DOI: 10.1016/j.jocn.2021.05.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 05/02/2021] [Accepted: 05/27/2021] [Indexed: 11/25/2022]
Abstract
Magnetic resonance imaging guided high intensity focused ultrasound (HIFU) has emerged as a tool offering incisionless intervention on brain tissue. The low risk and rapid recovery from this procedure, in addition to the ability to assess for clinical benefit and adverse events intraprocedurally, makes it an ideal tool for intervention upon brain networks both for clinical and research applications. This review article proposes that conceptualising brain focused ultrasound as a tool for brain network intervention and adoption of methodology to complement this approach may result in better clinical outcomes, fewer adverse events and may unveil or allow treatment opportunities not otherwise possible. A brief introduction to network neuroscience is discussed before a description of pathological brain networks is provided for a number of conditions for which MRI-guided brain HIFU intervention has been implemented. Essential Tremor is discussed as the most advanced example of MRI-guided brain HIFU intervention adoption along with the issues that present with this treatment modality compared to alternatives. The brain network intervention paradigm is proposed to overcome these issues and a number of examples of implementation of this are discussed. The ability of low intensity MRI guided focussed ultrasound to neuromoduate brain tissue without lesioning is introduced. This tool is discussed with regards to its potential clinical application as well as its potential to further our understanding of network neuroscience via its ability to interrogate brain networks without damaging tissue. Finally, a number of current clinical trials utilising brain focused ultrasound are discussed, along with the additional applications available from the utilisation of low intensity focused ultrasound.
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Affiliation(s)
- Fiona Permezel
- Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, Austin Hospital, Victoria, Australia.
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16
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Kim MJ, Park SH, Chang KW, Kim Y, Gao J, Kovalevsky M, Rachmilevitch I, Zadicario E, Chang WS, Jung HH, Chang JW. Technical and operative factors affecting magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: experience from 250 treatments. J Neurosurg 2021; 135:1780-1788. [PMID: 34020416 DOI: 10.3171/2020.11.jns202580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-guided focused ultrasound (MRgFUS) provides real-time monitoring of patients to assess tremor control and document any adverse effects. MRgFUS of the ventral intermediate nucleus (VIM) of the thalamus has become an effective treatment option for medically intractable essential tremor (ET). The aim of this study was to analyze the correlations of clinical and technical parameters with 12-month outcomes after unilateral MRgFUS thalamotomy for ET to help guide future clinical treatments. METHODS From October 2013 to January 2019, data on unilateral MRgFUS thalamotomy from the original pivotal study and continued-access studies from three different geographic regions were collected. Authors of the present study retrospectively reviewed those data and evaluated the efficacy of the procedure on the basis of improvement in the Clinical Rating Scale for Tremor (CRST) subscore at 1 year posttreatment. Safety was based on the rates of moderate and severe thalamotomy-related adverse events. Treatment outcomes in relation to various patient- and sonication-related parameters were analyzed in a large cohort of patients with ET. RESULTS In total, 250 patients were included in the present analysis. Improvement was sustained throughout the 12-month follow-up period, and 184 (73.6%) of 250 patients had minimal or no disability due to tremor (CRST subscore < 10) at the 12-month follow-up. Younger age and higher focal temperature (Tmax) correlated with tremor improvement in the multivariate analysis (OR 0.948, p = 0.013; OR 1.188, p = 0.025; respectively). However, no single statistically significant factor correlated with Tmax in the multivariate analysis. The cutoff value of Tmax in predicting a CRST subscore < 10 was 55.8°C. Skull density ratio (SDR) was positively correlated with heating efficiency (β = 0.005, p < 0.001), but no significant relationship with tremor improvement was observed. In the low-temperature group, 1-3 repetitions to the right target with 52°C ≤ Tmax ≤ 54°C was sufficient to generate sustained tremor suppression within the investigated follow-up period. The high-temperature group had a higher rate of balance disturbances than the low-temperature group (p = 0.04). CONCLUSIONS The authors analyzed the data of 250 patients with the aim of improving practices for patient screening and determining treatment endpoints. These results may improve the safety, efficacy, and efficiency of MRgFUS thalamotomy for ET.
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Affiliation(s)
- Myung Ji Kim
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - So Hee Park
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Kyung Won Chang
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Yuhee Kim
- 2InSightec Ltd., Tirat Carmel, Israel
| | - Jing Gao
- 2InSightec Ltd., Tirat Carmel, Israel
| | | | | | | | - Won Seok Chang
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Hyun Ho Jung
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Jin Woo Chang
- 1Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; and
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17
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Mo J, Priefer R. Medical Devices for Tremor Suppression: Current Status and Future Directions. BIOSENSORS-BASEL 2021; 11:bios11040099. [PMID: 33808056 PMCID: PMC8065649 DOI: 10.3390/bios11040099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 01/14/2023]
Abstract
Tremors are the most prevalent movement disorder that interferes with the patient’s daily living, and physical activities, ultimately leading to a reduced quality of life. Due to the pathophysiology of tremor, developing effective pharmacotherapies, which are only suboptimal in the management of tremor, has many challenges. Thus, a range of therapies are necessary in managing this progressive, aging-associated disorder. Surgical interventions such as deep brain stimulation are able to provide durable tremor control. However, due to high costs, patient and practitioner preference, and perceived high risks, their utilization is minimized. Medical devices are placed in a unique position to bridge this gap between lifestyle interventions, pharmacotherapies, and surgical treatments to provide safe and effective tremor suppression. Herein, we review the mechanisms of action, safety and efficacy profiles, and clinical applications of different medical devices that are currently available or have been previously investigated for tremor suppression. These devices are primarily noninvasive, which can be a beneficial addition to the patient’s existing pharmacotherapy and/or lifestyle intervention.
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18
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Chiu PY, Tzeng RC, Wei CY, Hung GU, Hu CJ. Tremor in Vascular Cognitive Impairment Raises the Possibility of Mixed Pathology With Lewy Body Disease. Front Neurosci 2020; 14:781. [PMID: 32903761 PMCID: PMC7438838 DOI: 10.3389/fnins.2020.00781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/02/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives Tremor is common in patients with Lewy body disease (LBD) and not rare in normal individuals. Prevalence of tremor in patients with vascular cognitive impairment (VCI) and its association with other comorbidities are seldom studied. The aim of this study was to investigate the patient characteristics of VCI associated with tremor and to evaluate the possibility of mixed pathology with LBD in these patients. Methods Retrospective analysis of a large population with VCI registered in the database of a regional healthcare system was performed. VCI patients were divided into tremor and non-tremor groups. The associated characteristics including demographics, clinical features in motor and non-motor domains, vascular risk factors, and neuroimaging features were compared between the tremor group and the non-tremor group. Results Among 1337 patients with VCI, 292 (21.8%) had tremor, while 1045 (78.2%) did not have tremor. The tremor group had significantly higher prevalence of all motor and non-motor LBD clinical features than the non-tremor group. The tremor group also demonstrated more severe neuropsychiatric symptoms. Among patients with tremor, patients having tremor onset earlier than stroke onset showed significantly higher prevalence of rapid eye movement sleep behavior disorder. All comparisons were adjusted for age and severity of dementia. Conclusion Tremor is a common comorbidity of VCI. VCI patients with tremor had a higher prevalence of motor and non-motor LBD features. These findings raised the possibility of VCI patients with tremor having high possibility of mixed pathology with LBD.
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Affiliation(s)
- Pai-Yi Chiu
- Department of Neurology, Show Chwan Memorial Hospital, Changhua, Taiwan.,Department of Nursing, College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
| | - Ray-Chang Tzeng
- Department of Neurology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan
| | - Guang-Uei Hung
- Department of Nuclear Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, Taipei Medical University-Shuang Ho Hospital, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
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19
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Robertson EE, Hall DA, Pal G, Ouyang B, Liu Y, Joyce JM, Berry-Kravis E, O'Keefe JA. Tremorography in fragile X-associated tremor/ataxia syndrome, Parkinson's disease and essential tremor. Clin Park Relat Disord 2020; 3:100040. [PMID: 34316626 PMCID: PMC8298795 DOI: 10.1016/j.prdoa.2020.100040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/07/2019] [Accepted: 11/22/2019] [Indexed: 11/25/2022] Open
Abstract
Background Fragile X-associated tremor/ataxia syndrome (FXTAS), a neurodegenerative disease affecting carriers of a 55-200 CGG repeat in the fragile X mental retardation 1 gene, may receive an initial diagnosis of Parkinson's disease (PD) or essential tremor (ET) due to overlapping motor symptoms. Therefore, tremor and bradykinesia were compared in these disorders using quantitative tremorography. Methods The inertial sensor based Kinesia ™ system was used to quantify upper extremity tremor and bradykinesia in participants with FXTAS (n = 25), PD (n = 23), ET (n = 18) and controls (n = 20) and regression analysis was performed to determine whether tremorography measures distinguished between the groups. The FXTAS Rating scale (FXTAS-RS) was administered to determine whether sub-score items on the clinician rated scale correlated with tremorography variables. Results FXTAS participants had reduced finger tap speed compared to those with ET, and ET had increased kinetic tremor compared to PD. Higher kinetic tremor distinguished FXTAS from PD (p = .02), and lower finger tap speed distinguished FXTAS from ET (p = .004). FXTAS-RS tremor and bradykinesia items correlated with tremorography measures (p = .005 to <0.0001). Conclusions This is the first quantitative study to compare tremor and bradykinesia in FXTAS, PD and ET. Kinetic tremor and bradykinesia measures using a quantitative inertial sensor system distinguished FXTAS from PD and ET, respectively. Such technologies may be useful for detecting precise tremor and bradykinesia abnormalities and distinguishing the tremor and bradykinesia profiles in each of these disorders.
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Affiliation(s)
- Erin E Robertson
- Department of Cell and Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Deborah A Hall
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States of America
| | - Gian Pal
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States of America
| | - Bichun Ouyang
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States of America
| | - Yuanqing Liu
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States of America
| | - Jessica M Joyce
- Department of Cell and Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Elizabeth Berry-Kravis
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States of America.,Department of Pediatrics, Rush University Medical Center, Chicago, IL, United States of America.,Department of Biochemistry, Rush University Medical Center, Chicago, IL, United States of America
| | - Joan A O'Keefe
- Department of Cell and Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America.,Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States of America.,Rush Medical College, Rush University Medical Center, Chicago, IL, United States of America
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20
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Alonso-Navarro H, García-Martín E, Agúndez JA, Jiménez-Jiménez FJ. Current and Future Neuropharmacological Options for the Treatment of Essential Tremor. Curr Neuropharmacol 2020; 18:518-537. [PMID: 31976837 PMCID: PMC7457404 DOI: 10.2174/1570159x18666200124145743] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/31/2019] [Accepted: 01/23/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Essential Tremor (ET) is likely the most frequent movement disorder. In this review, we have summarized the current pharmacological options for the treatment of this disorder and discussed several future options derived from drugs tested in experimental models of ET or from neuropathological data. METHODS A literature search was performed on the pharmacology of essential tremors using PubMed Database from 1966 to July 31, 2019. RESULTS To date, the beta-blocker propranolol and the antiepileptic drug primidone are the drugs that have shown higher efficacy in the treatment of ET. Other drugs tested in ET patients have shown different degrees of efficacy or have not been useful. CONCLUSION Injections of botulinum toxin A could be useful in the treatment of some patients with ET refractory to pharmacotherapy. According to recent neurochemical data, drugs acting on the extrasynaptic GABAA receptors, the glutamatergic system or LINGO-1 could be interesting therapeutic options in the future.
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Affiliation(s)
| | | | | | - Félix J. Jiménez-Jiménez
- Address correspondence to this author at the Section of Neurology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain; Tel: +34636968395; Fax: +34913280704; E-mails: ;
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21
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Sharma S, Pandey S. Treatment of essential tremor: current status. Postgrad Med J 2019; 96:84-93. [DOI: 10.1136/postgradmedj-2019-136647] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/14/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Essential tremor is the most common cause of tremor involving upper limbs, head and voice. The first line of treatment for limb tremor is pharmacotherapy with propranolol or primidone. However, these two drugs reduce the tremor severity by only half. In medication refractory and functionally disabling tremor, alternative forms of therapy need to be considered. Botulinum toxin injections are likely efficacious for limb, voice and head tremor but are associated with side effects. Surgical interventions include deep brain stimulation; magnetic resonance-guided focused ultrasound and thalamotomy for unilateral and deep brain stimulation for bilateral procedures. Recent consensus classification for essential tremor has included a new subgroup, ‘Essential tremor plus’, who have associated subtle neurological ‘soft signs’, such as dystonic posturing of limbs and may require a different treatment approach. In this review, we have addressed the current management of essential tremor with regard to different anatomical locations of tremor as well as different modalities of treatment.
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22
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Abstract
Essential tremor is one of the most common movement disorders in adults and can affect both children and adults. An updated consensus statement in 2018 redefined essential tremor as an isolated action tremor present in bilateral upper extremities for at least three years. Tremor may also be present in other locations, commonly the neck or the vocal cords. Patients with additional neurologic symptoms are now categorized as "essential tremor plus." Additional clinical features associated with the condition include but are not limited to cognitive impairment, psychiatric disorders, and hearing loss. When treatment is needed, propranolol and primidone are considered first line treatments. Patients who are severely affected are often offered deep brain stimulation. Although the ventral intermediate nucleus of the thalamus is the traditional surgical target, the caudal zona incerta is also being studied as a possible superior alternative. Magnetic resonance imaging guided high intensity focused ultrasound is a newer surgical alternative that may be ideal for patients with substantial medical comorbidities. Current research explores novel oral treatments, chemodenervation, and noninvasive neuromodulation for treatment of essential tremor.
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Affiliation(s)
- Vicki Shanker
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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23
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Kreisler A, Bouchain B, Defebvre L, Krystkowiak P. Treatment with Botulinum Neurotoxin Improves Activities of Daily Living and Quality of Life in Patients with Upper Limb Tremor. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2019; 9:tre-09-640. [PMID: 31413896 PMCID: PMC6691906 DOI: 10.7916/tohm.v0.640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 06/14/2019] [Indexed: 01/30/2023]
Abstract
Background Botulinum neurotoxin’s degree of effectiveness on upper limb tremor is subject to debate; although this treatment reduces the tremor’s amplitude, a clear functional benefit has not been demonstrated. The objective of this study was to assess the effect of botulinum neurotoxin type A treatment on activities of daily living and quality of life in patients with upper limb tremor. Methods We retrospectively examined the medical records of 50 consecutive patients treated with botulinum neurotoxin for upper limb tremor that was refractory to oral medication. One month after the injection, the patient was evaluated according to the Quality of Life in Essential Tremor Questionnaire, and the Essential Tremor Embarrassment Assessment. Results Full data sets were available for 38 patients suffering variously from essential tremor (n = 21), Holmes tremor secondary to a focal brain lesion (n = 8), idiopathic dystonic tremor (n = 4), primary writing tremor (n = 4), and Parkinson’s disease (n = 1). The Quality of Life Essential Tremor Questionnaire and the Essential Tremor Embarrassment Assessment scores improved significantly (p < 0.001) in the study population as a whole, and in the essential tremor and Holmes tremor subgroups. Discussion Botulinum neurotoxin treatment of patients with upper limb tremor is associated with improved quality of life and activities of daily living, irrespective of the tremor’s etiology. Long-term treatment enables the physician to adjust the injection strategy to the patient’s needs. Our study was limited by its retrospective design. The results must therefore be confirmed in a prospective, double-blind, placebo-controlled, randomized clinical trial.
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Affiliation(s)
| | | | - Luc Defebvre
- Neurologie et Pathologie du Mouvement, CHU Lille, Lille, FR
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24
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Niemann M, Schneider GH, Kühn A, Vajkoczy P, Faust K. Clinical Efficacy of Bilateral Deep Brain Stimulation Does Not Change After Implantable Pulse Generator Replacement but the Impedances Do: A Prospective Study. Neuromodulation 2019; 23:530-536. [PMID: 31323173 DOI: 10.1111/ner.13022] [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] [Received: 11/25/2018] [Revised: 05/13/2019] [Accepted: 06/12/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) is an approved therapy option for movement disorders such as Parkinson's disease (PD), essential Tremor (ET), and dystonia. While current research focuses on rechargeable implantable pulse generators (IPGs), little is known about changes of the motor functions after IPG replacement and the consequences of additionally implanted hardware. OBJECTIVE To assess changes of the motor functions, the therapy impedances, and the total electric energy delivered (TEED) after elective IPG replacement. METHODS We prospectively acquired the data of 47 patients with PD, ET, and dystonia treated with bilateral DBS. Motor functions were rated prior to and after surgery using the revised Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III), the Fahn-Tolosa-Marin Tremor-Rating-Scale (FTM-TRS), and the Unified Dystonia Rating Scale (UDRS). Furthermore, the therapy impedances and TEED were assessed at the aforementioned times. RESULTS While preoperative motor scores were 48.32 ± 17.16 in PD, 39.71 ± 12.28 in ET, and 18.48 ± 16.30 in dystonia patients, postoperative scores were 47.84 ± 24.33, 32.86 ± 15.82, and 15.02 ± 15.17, respectively. Only in dystonia patients, motor scores significantly differed. Perioperative therapy impedance changes were 142.66 ± 105.35 Ω (Kinetra® to Activa® PC), -68.75 ± 43.05 Ω (Activa® PC to Activa® PC), and - 51.38 ± 38.75 Ω (Activa® PC to Activa® RC). Perioperative TEED changes were - 37.15 ± 38.87 μJ, 2.03 ± 35.91 μJ, and 12.39 ± 6.31 μJ in that first, second, and third group, respectively. Both the therapy impedances and TEED significantly differed between groups. CONCLUSION Although there were no statistically significant changes in the motor functions of all patients after elective IPG replacement, the therapy impedances were significantly higher and TEED was significantly lower after IPG replacement with concurrent Pocket Adapter implantation.
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Affiliation(s)
- Marcel Niemann
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | | | - Andrea Kühn
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
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25
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Li C, Gajic-Veljanoski O, Schaink AK, Higgins C, Fasano A, Sikich N, Dhalla I, Ng V. Cost-Effectiveness of Magnetic Resonance-Guided Focused Ultrasound for Essential Tremor. Mov Disord 2018; 34:735-743. [PMID: 30589951 DOI: 10.1002/mds.27587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Radiofrequency thalamotomy and deep brain stimulation are current treatments for moderate to severe medication-refractory essential tremor. However, they are invasive and thus carry risks. Magnetic resonance-guided focused ultrasound is a new, less invasive surgical option. The objective of the present study was to determine the cost-effectiveness of magnetic resonance-guided focused ultrasound compared with standard treatments in Canada. METHODS We conducted a cost-utility analysis using a Markov cohort model. We compared magnetic resonance-guided focused ultrasound with no surgery in people ineligible for invasive neurosurgery and with radiofrequency thalamotomy and deep brain stimulation in people eligible for invasive neurosurgery. In the reference case analysis, we used a 5-year time horizon and a public payer perspective and discounted costs and benefits at 1.5% per year. RESULTS Compared with no surgery in people ineligible for invasive neurosurgery, magnetic resonance-guided focused ultrasound cost $21,438 more but yielded 0.47 additional quality-adjusted life years, producing an incremental cost-effectiveness ratio of $45,817 per quality-adjusted life year gained. In people eligible for invasive neurosurgery, magnetic resonance-guided focused ultrasound was slightly less effective but much less expensive compared with the current standard of care, deep brain stimulation. The results were sensitive to assumptions regarding the time horizon, cost of magnetic resonance-guided focused ultrasound, and probability of recurrence. CONCLUSIONS In people ineligible for invasive neurosurgery, the incremental cost-effectiveness ratio of magnetic resonance-guided focused ultrasound versus no surgery is comparable to many other tests and treatments that are widely adopted in high-income countries. In people eligible for invasive neurosurgery, magnetic resonance-guided focused ultrasound is also a reasonable option. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Chunmei Li
- Health Quality Ontario, Toronto, Ontario, Canada
| | | | | | | | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Centre, Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Nancy Sikich
- Health Quality Ontario, Toronto, Ontario, Canada
| | - Irfan Dhalla
- Health Quality Ontario, Toronto, Ontario, Canada
| | - Vivian Ng
- Health Quality Ontario, Toronto, Ontario, Canada
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Berardelli I, Pasquini M, Conte A, Bologna M, Berardelli A, Fabbrini G. Treatment of psychiatric disturbances in common hyperkinetic movement disorders. Expert Rev Neurother 2018; 19:55-65. [DOI: 10.1080/14737175.2019.1555475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed
| | - Matteo Bologna
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed
| | - Giovanni Fabbrini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed
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Differential effects of propranolol on head and upper limb tremor in patients with essential tremor and dystonia. J Neurol 2018; 265:2695-2703. [PMID: 30209649 DOI: 10.1007/s00415-018-9052-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 01/19/2023]
Abstract
Propranolol is used as the first-line treatment in essential tremor and it has also been proposed as a treatment for tremor in dystonia. However, several issues remain uncertain. For example, it is still not clear whether propranolol exerts a beneficial effect on head tremor. Moreover, no studies have investigated whether the effect of propranolol on head and upper limb tremor in essential tremor differs from that in dystonia. We aimed to assess the effects of propranolol on tremor in different body parts in essential tremor and in patients with tremor and dystonia. Twenty-nine patients with head and upper limb tremor were enrolled in the study, 14 with essential tremor, and 15 with dystonia. Participants underwent a clinical and kinematic analysis of tremor in two sessions, i.e., without (baseline) and 'on therapy' with propranolol. We found that head tremor was more severe in patients with dystonia, while upper limb tremor was more evident in patients with essential tremor (P < 0.05). Propranolol had no effect on head tremor in either group (all Ps > 0.05), but it did reduce upper limb tremor in patients with essential tremor. The present study demonstrates differential effects of propranolol on head and upper limb tremor in patients with essential tremor. The lack of effect on head and upper limb tremor in patients with dystonia suggests that the pathophysiological mechanisms underlying tremor in these two conditions and in different body parts may be distinct.
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Les mouvements anormaux : mise au point. Rev Med Interne 2018; 39:641-649. [DOI: 10.1016/j.revmed.2017.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/25/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022]
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Niemann M, Schneider GH, Kühn A, Vajkoczy P, Faust K. Longevity of Implantable Pulse Generators in Bilateral Deep Brain Stimulation for Movement Disorders. Neuromodulation 2017; 21:597-603. [DOI: 10.1111/ner.12743] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/17/2017] [Accepted: 11/02/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Marcel Niemann
- Department of Neurosurgery; Charité University Medicine Berlin; Berlin Germany
| | | | - Andrea Kühn
- Department of Neurosurgery; Charité University Medicine Berlin; Berlin Germany
| | - Peter Vajkoczy
- Department of Neurosurgery; Charité University Medicine Berlin; Berlin Germany
| | - Katharina Faust
- Department of Neurosurgery; Charité University Medicine Berlin; Berlin Germany
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Abstract
BACKGROUND Essential tremor (ET) is one of the most common movement disorders. The treatment is primarily based on pharmacological agents. Although primidone and propranolol are well established treatments in clinical practice, they can be ineffective in 25% to 55% of patients, and can produce serious adverse events in a large percentage of them. For these reasons, it may be worthwhile evaluating the treatment alternatives for ET. Zonisamide has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. OBJECTIVES To assess the effect on functional abilities and the safety profile of zonisamide in adults with essential tremor (ET). SEARCH METHODS We carried out a systematic search, without language restrictions to identify all relevant trials. We searched CENTRAL, MEDLINE, Embase, NICE, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) to January 2017. We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and examined the reference lists of identified studies and reviews. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of zonisamide versus placebo or any other treatment. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in patients presenting secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence.We used inverse variance methods for continuous outcomes and measurement scales. We compared differences between treatment groups as mean differences. We combined results for dichotomous outcomes using Mantel-Haenszel methods and obtained risk differences to compare treatment groups. We used Review Manager 5 software for data management and analysis. MAIN RESULTS We only considered one study eligible for this review (20 participants). Assessments of risk of bias for most domains were unclear or low. Adverse events were only reported in participants from the zonisamide group, making it possible that they were aware of treatment group assignment. We are uncertain as to the effects of zonisamide on motor tasks (mean difference (MD) -0.00, 95% confidence interval (CI) -1.51 to 1.51, very low-quality evidence) and functional disabilities (MD -0.30, 95% CI -1.23 to 0.63, very low-quality evidence) when compared with placebo. Three participants in the zonisamide group (30%) and two participants in the placebo group (20%) discontinued the treatment and withdrew from the study for any reason (very low-quality evidence), however the increased risk of withdrawal in the zonisamide group was statistically non-significant (risk difference (RD) 0.1, 95% CI -0.28 to 0.48). Six participants in the zonisamide group (60%) and none of the participants in the placebo group (0%) developed adverse events (AEs), with a RD of 0.60 (95% CI 0.28 to 0.92; very low quality evidence). The most common AEs, experienced with zonisamide treatment, were headache, nausea, fatigue, sleepiness, and diarrhoea. Quality of life was not assessed in the study included. AUTHORS' CONCLUSIONS Based on currently available data, there is insufficient evidence to assess the efficacy and safety of zonisamide treatment for ET.
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Affiliation(s)
- Elisa Bruno
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
| | - Alessandra Nicoletti
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
| | - Graziella Filippini
- Fondazione IRCCS, Istituto Neurologico Carlo BestaScientific Directionvia Celoria, 11MilanItaly20133
| | - Graziella Quattrocchi
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
| | - Carlo Colosimo
- Terni University HospitalDepartment of NeurologyTerniItaly05100
| | - Mario Zappia
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
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Rohani M, Fasano A. Focused Ultrasound for Essential Tremor: Review of the Evidence and Discussion of Current Hurdles. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:462. [PMID: 28503363 PMCID: PMC5425801 DOI: 10.7916/d8z89jn1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 04/17/2017] [Indexed: 01/09/2023]
Abstract
Background While there is no breakthrough progress in the medical treatment of essential tremor (ET), in the past decades several remarkable achievements happened in the surgical field, such as radiofrequency thalamotomy, thalamic deep brain stimulation, and gamma knife thalamotomy. The most recent advance in this area is magnetic resonance-guided focused ultrasound (MRgFUS). Methods The purpose of this review is to discuss the new developments and trials of MRgFUS in the treatment of ET and other tremor disorders. Results MRgFUS is an incisionless surgery performed without anesthesia and ionizing radiation (no risk of cumulative dose and delayed side effects). Studies have shown the safety and effectiveness of unilateral MRgFUS-thalamotomy in the treatment of ET. It has been successfully used in a few patients with Parkinson’s disease-related tremor, and in fewer patients with fragile X-associated tremor/ataxia syndrome. The safety and long-term effects of the procedure are still unclear, as temporary and permanent adverse events have been reported as well as recurrence of tremor. Discussion MRgFUS is a promising new surgical approach with a number of unknowns and unsolved issues. It represents a valuable option particularly for patients who refused or could not be candidates for other procedures, deep brain stimulation in particular.
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Affiliation(s)
- Mohammad Rohani
- Department of Neurology, Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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Bruno E, Nicoletti A, Quattrocchi G, Allegra R, Filippini G, Colosimo C, Zappia M. Topiramate for essential tremor. Cochrane Database Syst Rev 2017; 4:CD009683. [PMID: 28409827 PMCID: PMC6478240 DOI: 10.1002/14651858.cd009683.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Essential tremor (ET) is one of the most common movement disorders. The management is primarily based on pharmacological agents and in clinical practice propranolol and primidone are considered the first-line therapy. However, these treatments can be ineffective in 25% to 55% of people and are frequently associated with serious adverse events (AEs). For these reasons, it is worthwhile evaluating other treatments for ET. Topiramate has been suggested as a potentially useful agent for the treatment of ET but there is uncertainty about its efficacy and safety. OBJECTIVES To assess the efficacy and safety of topiramate in the treatment of ET. SEARCH METHODS We carried out a systematic search without language restrictions to identify all relevant trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to January 2017), Embase (January 1988 to January 2017), National Institute for Health and Care Excellence (1999 to January 2017), ClinicalTrials.gov (1997 to January 2017) and World Health Organization International Clinical Trials Registry Platform (ICTRP; 2004 to January 2017). We searched BIOSIS Citation Index (2000 to January 2017) for conference proceedings. We handsearched grey literature and the reference lists of identified studies and reviews. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of topiramate versus placebo/open control or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in people presenting with secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently collected and extracted data using a data collection form. We assessed the risk of bias and the quality of evidence. We used a fixed-effect meta-analysis for data synthesis. MAIN RESULTS This review included three trials comparing topiramate to placebo (309 participants). They were all at high overall risk of bias. The quality of evidence ranged from very low to low. Compared to placebo, participants treated with topiramate showed a significant improvement in functional disability and an increased risk of withdrawal (risk ratio (RR) 1.78, 95% confidence interval (CI) 1.23 to 2.60). There were more AEs for topiramate-treated participants, particularly paraesthesia, weight loss, appetite decrease and memory difficulty. AUTHORS' CONCLUSIONS This systematic review highlighted the presence of limited data and very low to low quality evidence to support the apparent efficacy and the occurrence of treatment-limiting AEs in people with ET treated with topiramate. Further research to assess topiramate efficacy and safety on ET is needed.
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Affiliation(s)
- Elisa Bruno
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
| | - Alessandra Nicoletti
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
| | - Graziella Quattrocchi
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
| | - Roberta Allegra
- Policlinico Universitario G. Martino MessinaDepartment of Neurological SciencesVia Consolare ValeriaMessinaItaly90100
| | - Graziella Filippini
- Fondazione IRCCS, Istituto Neurologico Carlo BestaScientific Directionvia Celoria, 11MilanItaly20133
| | - Carlo Colosimo
- Terni University HospitalDepartment of NeurologyTerniItaly05100
| | - Mario Zappia
- University of CataniaDepartment GF Ingrassia, Section of NeurosciencesCataniaItaly95123
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Kosmowska B, Ossowska K, Głowacka U, Wardas J. Tremorolytic effect of 5'-chloro-5'-deoxy-(±)-ENBA, a potent and selective adenosine A1 receptor agonist, evaluated in the harmaline-induced model in rats. CNS Neurosci Ther 2017; 23:438-446. [PMID: 28371468 DOI: 10.1111/cns.12692] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 01/19/2023] Open
Abstract
AIM The aim of this study was to examine the role of adenosine A1 receptors in the harmaline-induced tremor in rats using 5'-chloro-5'-deoxy-(±)-ENBA (5'Cl5'd-(±)-ENBA), a brain-penetrant, potent, and selective adenosine A1 receptor agonist. METHODS Harmaline was injected at a dose of 15 mg/kg ip and tremor was measured automatically in force-plate actimeters by an increased averaged power in the frequency band of 9-15 Hz (AP2) and by tremor index (a difference in power between AP2 and averaged power in the frequency band of 0-8 Hz). The zif-268 mRNA expression was additionally analyzed by in situ hybridization in several brain structures. RESULTS 5'Cl5'd-(±)-ENBA (0.05-0.5 mg/kg ip) dose dependently reduced the harmaline-induced tremor and this effect was reversed by 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), a selective antagonist of adenosine A1 receptors (1 mg/kg ip). Harmaline increased the zif-268 mRNA expression in the inferior olive, cerebellar cortex, ventroanterior/ventrolateral thalamic nuclei, and motor cortex. 5'Cl5'd-(±)-ENBA reversed these increases in all the above structures. DPCPX reduced the effect of 5'Cl5'd-(±)-ENBA on zif-268 mRNA in the motor cortex. CONCLUSION This study suggests that adenosine A1 receptors may be a potential target for the treatment of essential tremor.
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Affiliation(s)
- Barbara Kosmowska
- Department of Neuro-Psychopharmacology, Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Krystyna Ossowska
- Department of Neuro-Psychopharmacology, Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Urszula Głowacka
- Department of Neuro-Psychopharmacology, Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Jadwiga Wardas
- Department of Neuro-Psychopharmacology, Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
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Abstract
Functional neurosurgery has undergone rapid growth over the last few years fueled by advances in imaging technology and novel treatment modalities. These advances have led to new surgical treatments using minimally invasive and precise techniques for conditions such as Parkinson's disease, essential tremor, epilepsy, and psychiatric disorders. Understanding the goals and technological issues of these procedures is imperative for the anesthesiologist to ensure safe management of patients presenting for functional neurosurgical procedures. In this review, we discuss the advances in neurosurgical techniques for deep brain stimulation, focused ultrasound and minimally invasive laser-based treatment of refractory epilepsy and provide a guideline for anesthesiologists caring for patients undergoing these procedures.
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Sajonz BEA, Amtage F, Reinacher PC, Jenkner C, Piroth T, Kätzler J, Urbach H, Coenen VA. Deep Brain Stimulation for Tremor Tractographic Versus Traditional (DISTINCT): Study Protocol of a Randomized Controlled Feasibility Trial. JMIR Res Protoc 2016; 5:e244. [PMID: 28007690 PMCID: PMC5216255 DOI: 10.2196/resprot.6885] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 11/16/2022] Open
Abstract
Background Essential tremor is a movement disorder that can result in profound disability affecting the quality of life. Medically refractory essential tremor can be successfully reduced by deep brain stimulation (DBS) traditionally targeting the thalamic ventral intermediate nucleus (Vim). Although this structure can be identified with magnetic resonance (MR) imaging nowadays, Vim-DBS electrodes are still implanted in the awake patient with intraoperative tremor testing to achieve satisfactory tremor control. This can be attributed to the fact that the more effective target of DBS seems to be the stimulation of fiber tracts rather than subcortical nuclei like the Vim. There is evidence that current coverage of the dentatorubrothalamic tract (DRT) results in good tremor control in Vim-DBS. Diffusion tensor MR imaging (DTI) tractography-assisted stereotactic surgery targeting the DRT would therefore not rely on multiple trajectories and intraoperative tremor testing in the awake patient, bearing the potential of more patient comfort and reduced operation-related risks. This is the first randomized controlled trial comparing DTI tractography-assisted stereotactic surgery targeting the DRT in general anesthesia with stereotactic surgery of thalamic/subthalamic region as conventionally used. Objective This clinical pilot trial aims at demonstrating safety of DTI tractography-assisted stereotactic surgery in general anesthesia and proving its equality compared to conventional stereotactic surgery with intraoperative testing in the awake patient. Methods The Deep Brain Stimulation for Tremor Tractographic Versus Traditional (DISTINCT) trial is a single-center investigator-initiated, randomized, controlled, observer-blinded trial. A total of 24 patients with medically refractory essential tremor will be randomized to either DTI tractography-assisted stereotactic surgery targeting the DRT in general anesthesia or stereotactic surgery of the thalamic/subthalamic region as conventionally used. The primary objective is to assess the tremor reduction, obtained by the Fahn-Tolosa-Marin Tremor Rating Scale in the 2 treatment groups. Secondary objectives include (among others) assessing the quality of life, optimal electrode contact positions, and safety of the intervention. The study protocol has been approved by the independent ethics committee of the University of Freiburg. Results Recruitment to the DISTINCT trial opened in September 2015 and is expected to close in June 2017. At the time of manuscript submission the trial is open to recruitment. Conclusions The DISTINCT trial is the first to compare DTI tractography-assisted stereotactic surgery with target point of the DRT in general anesthesia to stereotactic surgery of the thalamic/subthalamic region as conventionally used. It can serve as a cornerstone for the evolving technique of DTI tractography-assisted stereotactic surgery. ClinicalTrial ClinicalTrials.gov NCT02491554; https://clinicaltrials.gov/ct2/show/NCT02491554 (Archived by WebCite at http://www.webcitation.org/6mezLnB9D). German Clinical Trials Register DRKS00008913; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008913 (Archived by WebCite at http://www.webcitation.org/6mezCtxhS).
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Affiliation(s)
- Bastian Elmar Alexander Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Amtage
- Department of Neurology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Christoph Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carolin Jenkner
- Clinical Trials Unit Freiburg, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Piroth
- Department of Neurology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Kätzler
- Clinical Trials Unit Freiburg, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker Arnd Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Bruno E, Nicoletti A, Quattrocchi G, Filippini G, Colosimo C, Zappia M. Pregabalin for essential tremor. Cochrane Database Syst Rev 2016; 10:CD009682. [PMID: 27763691 PMCID: PMC6461190 DOI: 10.1002/14651858.cd009682.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Essential tremor is one of the most common movement disorders. Treatment primarily consists of pharmacological agents. While primidone and propranolol are well-established treatments in clinical practice, they may be ineffective in 25% to 55% of patients and can produce serious adverse events in a large percentage of them. For these reasons, it is worth evaluating the treatment alternatives for essential tremor. Some specialists have suggested that pregabalin could be a potentially useful agent, but there is uncertainty about its efficacy and safety. OBJECTIVES To assess the effects of pregabalin versus placebo or other treatment for essential tremor in adults. SEARCH METHODS We performed a systematic search without language restrictions to identify all relevant trials up to December 2015. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, NICE, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We handsearched grey literature and examined the reference lists of identified studies and reviews. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of pregabalin versus placebo or any other treatments. We included studies in which the diagnosis of ET was made according to accepted and validated diagnostic criteria. We excluded studies conducted in patients presenting secondary forms of tremor or reporting only neurophysiological parameters to assess outcomes. DATA COLLECTION AND ANALYSIS Two reviewers independently collected and extracted data using a data collection form. We assessed the risk of bias of the body of evidence, and we used inverse variance methods to analyse continuous outcomes and measurement scales. We compared the mean difference between treatment groups, and we combined results for dichotomous outcomes using Mantel-Haenszel methods and risk differences We used Review Manager software for data management and analysis. MAIN RESULTS We only found one study eligible for this review (22 participants). We assessed the risk of bias for most domains as unclear. We graded the overall quality of evidence as very low. Compared to placebo, patients treated with pregabalin showed no significant improvement of motor tasks on the 36-point subscale of the Fahn-Tolosa-Marin Tremor Rating Scale (TRS) (MD -2.15 points; 95% CI -9.16 to 4.86) or on the 32-point functional abilities subscale of the TRS (MD -0.66 points; 95% CI -2.90 to 1.58).The limited evidence showed no difference in study withdrawal (Mantel-Haenszel RD -0.09; 95% CI -0.48 to 0.30) and presentation of adverse events between pregabalin and placebo (Mantel-Haenszel RD 0.18; 95% CI -0.13 to 0.50). AUTHORS' CONCLUSIONS The effects of pregabalin for treating essential tremor are uncertain because the quality of the evidence is very low. One small study did not highlight any effect of this treatment; however, the high risk of bias and the lack of other studies on this topic limit further conclusion.
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Affiliation(s)
- Elisa Bruno
- Department GF Ingrassia,Section of Neurosciences, University of Catania, Catania, Italy, 95123
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Barbe MT, Franklin J, Kraus D, Reker P, Dembek TA, Allert N, Wirths J, Voges J, Timmermann L, Visser-Vandewalle V. Deep brain stimulation of the posterior subthalamic area and the thalamus in patients with essential tremor: study protocol for a randomized controlled pilot trial. Trials 2016; 17:476. [PMID: 27687972 PMCID: PMC5043531 DOI: 10.1186/s13063-016-1599-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 09/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus is effective in medication refractory essential tremor (ET). In recent years, evidence has accumulated that the region ventral to the VIM, the posterior subthalamic area (PSA), might be an equally or even more effective target for electrode implantation. However, this evidence is primarily based on case series, cross-sectional observations, and retrospective data. METHODS/DESIGN A prospective crossover pilot study investigating the effects of PSA stimulation in medication refractory ET patients was designed. In this study, bilateral electrodes are implanted such that at least one of the electrode contacts is located in the PSA and VIM, respectively. This implantation approach allows (1) a prospective double-blind investigation of the effects of PSA stimulation compared to baseline, as well as (2) a crossover comparison between VIM and PSA stimulation with respect to tremor suppression and side effect profiles. DISCUSSION The results of this double-blinded, prospective study will allow a better understanding of the effects and side effects of PSA compared to VIM-DBS in patients with ET. TRIAL REGISTRATION German Clinical Trials Register: DRKS00004235 . Registered on 4 July 2012.
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Affiliation(s)
- Michael T Barbe
- Department of Neurology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany. .,Cognitive Neuroscience (INM3), Institute of Neuroscience and Medicine, Research Centre Jülich, Jülich, Germany.
| | - Jeremy Franklin
- Institute of Medical Statistics, Informatics and Epidemiology, University Cologne, Cologne, Germany
| | - Daria Kraus
- Clinical Trials Centre Cologne, Cologne, Germany
| | - Paul Reker
- Department of Neurology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till A Dembek
- Department of Neurology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Jochen Wirths
- Department of Stereotactic and Functional Neurosurgery, University Hospital Cologne, Kerpener Str. 62, D-50937, Cologne, Germany
| | - Jürgen Voges
- Department of Stereotactic Neurosurgery, University Hospital Magdeburg, Magdeburg, Germany.,Leibniz Institute for Neurobiology (LIN), Magdeburg, Germany
| | - Lars Timmermann
- Department of Neurology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University Hospital Cologne, Kerpener Str. 62, D-50937, Cologne, Germany.
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Robertson EE, Hall DA, McAsey AR, O'Keefe JA. Fragile X-associated tremor/ataxia syndrome: phenotypic comparisons with other movement disorders. Clin Neuropsychol 2016; 30:849-900. [PMID: 27414076 PMCID: PMC7336900 DOI: 10.1080/13854046.2016.1202239] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 06/12/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this paper is to review the typical cognitive and motor impairments seen in fragile X-associated tremor/ataxia syndrome (FXTAS), essential tremor (ET), Parkinson disease (PD), spinocerebellar ataxias (SCAs), multiple system atrophy (MSA), and progressive supranuclear palsy (PSP) in order to enhance diagnosis of FXTAS patients. METHODS We compared the cognitive and motor phenotypes of FXTAS with each of these other movement disorders. Relevant neuropathological and neuroimaging findings are also reviewed. Finally, we describe the differences in age of onset, disease severity, progression rates, and average lifespan in FXTAS compared to ET, PD, SCAs, MSA, and PSP. We conclude with a flow chart algorithm to guide the clinician in the differential diagnosis of FXTAS. RESULTS By comparing the cognitive and motor phenotypes of FXTAS with the phenotypes of ET, PD, SCAs, MSA, and PSP we have clarified potential symptom overlap while elucidating factors that make these disorders unique from one another. In summary, the clinician should consider a FXTAS diagnosis and testing for the Fragile X mental retardation 1 (FMR1) gene premutation if a patient over the age of 50 (1) presents with cerebellar ataxia and/or intention tremor with mild parkinsonism, (2) has the middle cerebellar peduncle (MCP) sign, global cerebellar and cerebral atrophy, and/or subcortical white matter lesions on MRI, or (3) has a family history of fragile X related disorders, intellectual disability, autism, premature ovarian failure and has neurological signs consistent with FXTAS. Peripheral neuropathy, executive function deficits, anxiety, or depression are supportive of the diagnosis. CONCLUSIONS Distinct profiles in the cognitive and motor domains between these movement disorders may guide practitioners in the differential diagnosis process and ultimately lead to better medical management of FXTAS patients.
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Affiliation(s)
- Erin E Robertson
- a Department of Anatomy and Cell Biology , Rush University , Chicago , IL , USA
| | - Deborah A Hall
- b Department of Neurological Sciences , Rush University , Chicago , IL , USA
| | - Andrew R McAsey
- a Department of Anatomy and Cell Biology , Rush University , Chicago , IL , USA
| | - Joan A O'Keefe
- a Department of Anatomy and Cell Biology , Rush University , Chicago , IL , USA
- b Department of Neurological Sciences , Rush University , Chicago , IL , USA
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Picillo M, Lozano AM, Kou N, Munhoz RP, Fasano A. Programming Deep Brain Stimulation for Tremor and Dystonia: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:438-452. [DOI: 10.1016/j.brs.2016.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022] Open
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Canel L, Zisimopoulou S, Besson M, Nendaz M. Topiramate-induced severe heatstroke in an adult patient: a case report. J Med Case Rep 2016; 10:95. [PMID: 27075033 PMCID: PMC4831160 DOI: 10.1186/s13256-016-0835-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/12/2016] [Indexed: 11/11/2022] Open
Abstract
Background Heatstroke is a life-threatening condition defined by failure of heat load dissipation, resulting in a core temperature higher than 40 °C (104 °F) associated with neurological dysfunction. Topiramate may cause anhidrosis, potentially resulting in heatstroke, as reported especially in children. Case presentation A 57-year-old Caucasian man was admitted to the emergency room in a febrile comatose state. After a complete workup ruling out the usual etiologies of such a condition, we assumed the hypothesis of a heatstroke caused by topiramate, recently prescribed for essential tremor. Conclusions Topiramate-related heatstroke has been described in children but must be recognized in adults as well. Outcomes may range from total clinical recovery to persistent neurological dysfunction or death. The prescription of topiramate and the follow-up of adult patients under this medication should include an evaluation of hypohidrosis, especially in contexts of high temperature.
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Affiliation(s)
- Lucie Canel
- Department of Internal Medicine, HUG Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
| | - Sofia Zisimopoulou
- Department of Community Medicine, HUG Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Marie Besson
- Department of Clinical Pharmacology and Toxicology, HUG Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Mathieu Nendaz
- Department of Internal Medicine, HUG Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
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42
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Chunling W, Zheng X. Review on clinical update of essential tremor. Neurol Sci 2016; 37:495-502. [DOI: 10.1007/s10072-015-2380-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/08/2015] [Indexed: 01/03/2023]
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Bruno E, Nicoletti A, Quattrocchi G, Filippini G, Zappia M, Colosimo C. Alprazolam for essential tremor. Cochrane Database Syst Rev 2015; 2015:CD009681. [PMID: 26638213 PMCID: PMC7387361 DOI: 10.1002/14651858.cd009681.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Essential tremor (ET) is one of the most common movement disorders. Treatment is based primarily on pharmacological agents. On this basis, although primidone and propranolol are well-established treatments in clinical practice, they could be ineffective in 25% to 55% of patients and can produce serious adverse events (AEs) in a large percentage of individuals. For these reasons, evaluating treatment alternatives for ET may be a worthwhile pursuit. Alprazolam has been suggested as a potentially useful agent for treatment of individuals with ET, but its efficacy and safety are uncertain. OBJECTIVES PrimaryTo assess the efficacy and safety of alprazolam in the treatment of individuals with ET. SecondaryTo examine effects of alprazolam treatment on the quality of life of people with ET. SEARCH METHODS We carried out a systematic search without language restrictions to identify all relevant trials. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to September 2015), EMBASE (January 1988 to September 2015), the National Institute for Health and Care Excellence (NICE) (1999 to September 2015), ClinicalTrials.gov (1997 to September 2015) and the World Health Organiza tion (WHO) International Clinical Trials Registry Platform (ICTRP) (2004 to September 2015). We handsearched grey literature and examined the reference lists of identified studies and reviews. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of alprazolam versus placebo or any other treatment. We included studies in which ET was diagnosed according to accepted and validated diagnostic criteria. We excluded studies that included patients presenting with secondary forms of tremor or reporting only neurophysiological parameters for the pur p ose of assessing outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently collected and extracted data using a data collection form. We assessed risk of bias and the body of evidence. We used inverse variance methods for continuous outcomes and measurement scales. We compared differences between treatment groups as mean differences. We used Review Manager software for management and analysis of data. MAIN RESULTS We included in this review one trial that compared alprazolam versus placebo (24 participants). It was judged to have high overall risk of bias. We graded the overall quality of evidence as very low. Compared with those given placebo, participants treated with alprazolam showed a significant reduction in tremor severity (mean difference (MD) -0.75, 95% confidence interval (CI) -0.83 to -0.67). Nine alprazolam-treated participants (75%) developed AEs, mainly represented by sedation (50%), constipation (17%) and dry mouth (9%). No participants in the alprazolam group and no p articipants in the placebo group discontinued treatment and dropped out of the study. AUTHORS' CONCLUSIONS Currently available data reveal evidence insufficient for assessment of the efficacy and safety of alprazolam treatment for individuals with ET.
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Affiliation(s)
- Elisa Bruno
- Department GF Ingrassia,Section of Neurosciences, University of Catania, Catania, Italy, 95123
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Fasano A, Deuschl G. Therapeutic advances in tremor. Mov Disord 2015; 30:1557-65. [DOI: 10.1002/mds.26383] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/29/2015] [Indexed: 12/12/2022] Open
Affiliation(s)
- Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital-UHN, Division of Neurology, University of Toronto; Toronto Ontario Canada
| | - Günther Deuschl
- Department of Neurology; Christian-Albrechts-University Kiel; Germany
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Ossowska K, Głowacka U, Kosmowska B, Wardas J. Apomorphine enhances harmaline-induced tremor in rats. Pharmacol Rep 2015; 67:435-41. [DOI: 10.1016/j.pharep.2014.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/08/2014] [Accepted: 11/13/2014] [Indexed: 10/24/2022]
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Agúndez JA, Jiménez-Jimenez FJ, Alonso-Navarro H, García-Martín E. The potential of LINGO-1 as a therapeutic target for essential tremor. Expert Opin Ther Targets 2015; 19:1139-48. [PMID: 25862159 DOI: 10.1517/14728222.2015.1028360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION LINGO-1 is a negative regulator of neuronal survival, oligodendrocyte differentiation and axonal outgrowth and regeneration, because it interacts with diverse growth factor receptors blocking or inhibiting their action. Consistent findings obtained in vitro and in animal models suggest that anti-LINGO-1 therapy may be useful in neurodegenerative disorders such as multiple sclerosis (MS), Parkinson's disease or essential tremor (ET). Moreover, genetic and pathological evidence provide a robust link between LINGO-1 and ET. AREAS COVERED In this review, we present an overview of current knowledge on findings linking LINGO-1 and ET, with a special focus on genetic linkage, we include an overview of LINGO1 gene variations according to the 1000 genomes catalog, and we identify potential gene areas where common changes occur because, as well as the risk developing ET, LINGO1 genetic changes may influence the response to anti-LINGO-1 therapy. EXPERT OPINION The goal of anti-LINGO-1 therapy in neurodegenerative diseases is to ease the brakes of neuronal growth and recovery. An anti-LINGO-1 antibody is under clinical trials for MS patients. Before planning trials with ET patients, refinement on the genetic link between LINGO1 and ET, and a detailed genetic and phenotypic assessment of ET patients to be enrolled, should be carried out.
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Affiliation(s)
- José Ag Agúndez
- University of Extremadura, Department of Pharmacology , Avda. de la Universidad s/n, E-10071, Cáceres , Spain +34927257000 Ext 86897 ; +34924289676 ;
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Impact of advancing age on post-operative complications of deep brain stimulation surgery for essential tremor. J Clin Neurosci 2015; 22:872-6. [PMID: 25669119 DOI: 10.1016/j.jocn.2014.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/31/2014] [Accepted: 11/03/2014] [Indexed: 11/22/2022]
Abstract
Essential tremor (ET) was the original indication for deep brain stimulation (DBS), with USA Food and Drug Administration approval since 1997. Despite the efficacy of DBS, it is associated with surgical complications that cause sub-optimal clinical outcomes. Given that ET is a progressive disease with increase in symptom severity with increasing age, this study evaluated the impact of increasing age on short-term complications following DBS surgery for ET. The Thomson-Reuters MarketScan database was utilized (New York, NY, USA). Patients selected were over age 18 and underwent DBS for ET between the years 2000 and 2009. Multivariable logistic regression analysis was used to calculate complication odds ratios (OR) for a 5 year increase in age, after controlling for other covariates. Six hundred sixty-one patients were included in the analysis. The mean (standard deviation) age was 61.9 (14.3) years, with 17% of individuals aged ⩾75 years. Overall 56.9% of patients were male, and 44.6% had a Charlson Comorbidity Score of ⩾1. Additionally, 7.1% of patients experienced at least one complication within 90 days, including wound infections (3.0%), pneumonia (2.4%), hemorrhage or hematoma (1.5%), or pulmonary embolism (0.6%). Increasing age was not significantly associated with the overall 90 day complication rates (OR 0.89; 95% confidence interval [CI] 0.77-1.02; p=0.102). The risk of the two most common procedure-related complications, hemorrhage and infection, did not significantly increase with age (hemorrhage: OR 1.02; 95%CI 0.77-1.37; p=0.873; and infection: OR 0.88; 95%CI 0.72-1.07; p=0.203). Our findings suggest that age should not be a primary exclusion factor for determining candidacy for DBS and also suggest a possible expansion of the traditional therapeutic window since post-operative complications remained relatively stable.
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Langley A, Pope E. Propranolol and central nervous system function: potential implications for paediatric patients with infantile haemangiomas. Br J Dermatol 2014; 172:13-23. [PMID: 25175684 DOI: 10.1111/bjd.13379] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2014] [Indexed: 12/12/2022]
Abstract
Given its improved safety profile compared with systemic corticosteroids, propranolol has become the mainstay treatment of infantile haemangioma (IH) worldwide. There is evidence, mainly from adult volunteer studies, that propranolol use is associated with central nervous system (CNS) effects. Impairment to short- and long-term memory, psychomotor function, sleep quality and mood with relatively low doses and durations of treatment have been reported. The exact magnitude of CNS effects resulting from propranolol use, especially in the early developmental stages and for prolonged periods of use, is not currently known. These effects may not be readily recognizable and require specialized assessment of cognitive function not routinely performed. Furthermore, there may be a delay between exposure and cognitive defects. The evidence to date provides a strong rationale to proceed with caution when prescribing propranolol for IH: treatment should be used only when indicated (in the presence of ulceration, impairment of a vital function or risk of permanent disfigurement) and for a limited duration, and the benefits of treatment should be weighed carefully against potential adverse events before treatment is initiated. This narrative review describes the evidence for an effect of propranolol use on CNS function from volunteer and patient studies, including IH.
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Affiliation(s)
- A Langley
- The Hospital for Sick Children, Toronto, ON, Canada
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49
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Bendersky D, Ajler P, Yampolsky C. [The use of neuromodulation for the treatment of tremor]. Surg Neurol Int 2014; 5:S232-46. [PMID: 25165613 PMCID: PMC4138824 DOI: 10.4103/2152-7806.137944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tremor may be a disabling disorder and pharmacologic treatment is the first-line therapy for these patients. Nevertheless, this treatment may lead to a satisfactory tremor reduction in only 50% of patients with essential tremor. Thalamotomy was the treatment of choice for tremor refractory to medical therapy until deep brain stimulation (DBS) of the ventral intermedius nucleus (Vim) of the thalamus has started being used. Nowadays, thalamotomy is rarely performed. METHODS This article is a non-systematic review of the indications, results, programming parameters and surgical technique of DBS of the Vim for the treatment of tremor. RESULTS In spite of the fact that it is possible to achieve similar clinical results using thalamotomy or DBS of the Vim, the former causes more adverse effects than the latter. Furthermore, DBS can be used bilaterally, whereas thalamotomy has a high risk of causing disartria when it is performed in both sides. DBS of the Vim achieved an adequate tremor improvement in several series of patients with tremor caused by essential tremor, Parkinson's disease or multiple sclerosis. Besides the Vim, there are other targets, which are being used by some authors, such as the zona incerta and the prelemniscal radiations. CONCLUSION DBS of the Vim is a useful treatment for disabling tremor refractory to medical therapy. It is essential to carry out an accurate patient selection as well as to use a proper surgical technique. The best stereotactic target for tremor is still unknown, although the Vim is the most used one.
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Affiliation(s)
- Damián Bendersky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Claudio Yampolsky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Rajput AH, Rajput A. Medical treatment of essential tremor. J Cent Nerv Syst Dis 2014; 6:29-39. [PMID: 24812533 PMCID: PMC3999812 DOI: 10.4137/jcnsd.s13570] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/10/2014] [Accepted: 03/12/2014] [Indexed: 11/05/2022] Open
Abstract
Essential tremor (ET) is the most common pathological tremor characterized by upper limb action-postural tremor (PT)/kinetic tremor (KT). There are no specific neuropathological or biochemical abnormalities in ET. The disability is consequent to amplitude of KT, which may remain mild without handicap or may become disabling. The most effective drugs for sustained tremor control are propranolol and primidone. Symptomatic drug treatment must be individualized depending on the circumstances that provoke the tremor-related disability. Broad guidelines for treatment are discussed in this review. Patients may be treated intermittently only on stressful occasions with propranolol, clonazepam, or primidone monotherapy, or an alcoholic drink. Those with persistently disabling tremor need continued treatment.
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Affiliation(s)
- Ali H Rajput
- University of Saskatchewan, Canada
- Saskatoon Health Region, Canada
| | - Alex Rajput
- University of Saskatchewan, Canada
- Saskatoon Health Region, Canada
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