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Lefaucheur JP, Moro E, Shirota Y, Ugawa Y, Grippe T, Chen R, Benninger DH, Jabbari B, Attaripour S, Hallett M, Paulus W. Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter. Clin Neurophysiol 2024; 164:57-99. [PMID: 38852434 DOI: 10.1016/j.clinph.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/02/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Clinical Neurophysiology Unit, Henri Mondor University Hospital, AP-HP, Créteil, France; EA 4391, ENT Team, Paris-Est Créteil University, Créteil, France.
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, CHU of Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Yuichiro Shirota
- Department of Neurology, Division of Neuroscience, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikazu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Talyta Grippe
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Neuroscience Graduate Program, Federal University of Minas Gerais, Belo Horizonte, Brazil; Krembil Brain Institute, Toronto, Ontario, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada
| | - David H Benninger
- Service of Neurology, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Walter Paulus
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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Kaplitt MG, Krishna V, Eisenberg HM, Elias WJ, Ghanouni P, Baltuch GH, Rezai A, Halpern CH, Dalm B, Fishman PS, Buch VP, Moosa S, Sarva H, Murray AM. Safety and Efficacy of Staged, Bilateral Focused Ultrasound Thalamotomy in Essential Tremor: An Open-Label Clinical Trial. JAMA Neurol 2024:2821255. [PMID: 39073822 PMCID: PMC11287440 DOI: 10.1001/jamaneurol.2024.2295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/31/2024] [Indexed: 07/30/2024]
Abstract
Importance Unilateral magnetic resonance-guided focused ultrasound ablation of ventralis intermedius nucleus of the thalamus for essential tremor reduces tremor on 1 side, but untreated contralateral or midline symptoms remain limiting for some patients. Historically, bilateral lesioning produced unacceptable risks and was supplanted by deep brain stimulation; increasing acceptance of unilateral focused ultrasound lesioning has led to interest in a bilateral option. Objective To evaluate the safety and efficacy of staged, bilateral focused ultrasound thalamotomy. Design, Setting, and Participants This prospective, open-label, multicenter trial treated patients with essential tremor from July 2020 to October 2021, with a 12-month follow-up, at 7 US academic medical centers. Of 62 enrolled patients who had undergone unilateral focused ultrasound thalamotomy at least 9 months prior to enrollment, 11 were excluded and 51 were treated. Eligibility criteria included patient age (22 years and older), medication refractory, tremor severity (Clinical Rating Scale for Tremor [CRST] part A score ≥2 for postural or kinetic tremor), and functional disability (CRST part C score ≥2 in any category). Intervention A focused ultrasound system interfaced with magnetic resonance imaging allowed real-time alignment of thermography maps with anatomy. Subthreshold sonications allowed target interrogation for efficacy and off-target effects before creating an ablation. Main Outcomes and Measures Tremor/motor score (CRST parts A and B) at 3 months for the treated side after treatment was the primary outcome measure, and secondary assessments for efficacy and safety continued to 12 months. Results The mean (SD) population age was 73 (13.9) years, and 44 participants (86.3%) were male. The mean (SD) tremor/motor score improved from 17.4 (5.4; 95% CI, 15.9-18.9) to 6.4 (5.3; 95% CI, 4.9 to 7.9) at 3 months (66% improvement in CRST parts A and B scores; 95% CI, 59.8-72.2; P < .001). There was significant improvement in mean (SD) postural tremor (from 2.5 [0.8]; 95% CI, 2.3 to 2.7 to 0.6 [0.9]; 95% CI, 0.3 to 0.8; P < .001) and mean (SD) disability score (from 10.3 [4.7]; 95% CI, 9.0-11.6 to 2.2 [2.8]; 95% CI, 1.4-2.9; P < .001). Twelve participants developed mild (study-defined) ataxia, which persisted in 6 participants at 12 months. Adverse events (159 of 188 [85%] mild, 25 of 188 [13%] moderate, and 1 severe urinary tract infection) reported most commonly included numbness/tingling (n = 17 total; n = 8 at 12 months), dysarthria (n = 15 total; n = 7 at 12 months), ataxia (n = 12 total; n = 6 at 12 months), unsteadiness/imbalance (n = 10 total; n = 0 at 12 months), and taste disturbance (n = 7 total; n = 3 at 12 months). Speech difficulty, including phonation, articulation, and dysphagia, were generally mild (rated as not clinically significant, no participants with worsening in all 3 measures) and transient. Conclusions and Relevance Staged, bilateral focused ultrasound thalamotomy significantly reduced tremor severity and functional disability scores. Adverse events for speech, swallowing, and ataxia were mostly mild and transient. Trial Registration ClinicalTrials.gov Identifier NCT04112381.
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Affiliation(s)
- Michael G. Kaplitt
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York
| | - Vibhor Krishna
- Department of Neurosurgery, University of North Carolina, Chapel Hill
| | | | - W. Jeffrey Elias
- Department of Neurosurgery, University of Virginia, Charlottesville
| | - Pejman Ghanouni
- Department of Radiology, Stanford University, Stanford, California
| | | | - Ali Rezai
- Department of Neurosurgery, West Virginia University, Morgantown
| | - Casey H. Halpern
- Department of Neurosurgery, University of Pennsylvania, Philadelphia
| | - Brian Dalm
- Department of Neurosurgery, The Ohio State University, Columbus
| | | | - Vivek P. Buch
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Shayan Moosa
- Department of Neurosurgery, University of Virginia, Charlottesville
| | - Harini Sarva
- Department of Neurology, Cornell University, New York, New York
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Purrer V, Pohl E, Borger V, Weiland H, Boecker H, Schmeel FC, Wüllner U. Motor and non-motor outcome in tremor dominant Parkinson's disease after MR-guided focused ultrasound thalamotomy. J Neurol 2024; 271:3731-3742. [PMID: 38822147 PMCID: PMC11233288 DOI: 10.1007/s00415-024-12469-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an emerging technique for the treatment of severe, medication-refractory tremor syndromes. We here report motor and non-motor outcomes 6 and 12 months after unilateral MRgFUS thalamotomy in tremor-dominant Parkinson's disease (tdPD). METHODS 25 patients with tdPD underwent neuropsychological evaluation including standardized questionnaires of disability, quality of life (QoL), mood, anxiety, apathy, sleep disturbances, and cognition at baseline, 6 and 12 months after MRgFUS. Motor outcome was evaluated using the Clinical Rating Scale for Tremor (CRST) and Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). In addition, side effects and QoL of family caregivers were assessed. RESULTS 12 months after MRgFUS significant improvements were evident in the tremor subscores. Patients with concomitant rest and postural tremor showed better tremor outcomes compared to patients with predominant rest tremor. There were no differences in the non-motor assessments. No cognitive decline was observed. Side effects were mostly transient (54%) and classified as mild (62%). No changes in the caregivers' QoL could be observed. CONCLUSION We found no changes in mood, anxiety, apathy, sleep, cognition or persistent worsening of gait disturbances after unilateral MRgFUS thalamotomy in tdPD. Concomitant postural tremors responded better to treatment than predominant rest tremors.
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Affiliation(s)
- Veronika Purrer
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany.
| | - Emily Pohl
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hannah Weiland
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Henning Boecker
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Frederic Carsten Schmeel
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Ullrich Wüllner
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre of Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany
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Aubignat M, Tir M, Ouendo M, Boussida S, Constans JM, Lefranc M. Unilateral Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy Thalamotomy for Essential Tremor. Mov Disord 2024; 39:1006-1014. [PMID: 38532534 DOI: 10.1002/mds.29790] [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: 08/27/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Essential tremor (ET) affects numerous adults, impacting quality of life (QOL) and often defying pharmacological treatment. Surgical interventions like deep brain stimulation (DBS) and lesional approaches, including radiofrequency, gamma-knife radiosurgery, and magnetic resonance imaging (MRI)-guided focused ultrasound, offer solutions but are not devoid of limitations. OBJECTIVES This retrospective, single-center, single-blinded pilot study aimed to assess the safety and efficacy of unilateral MRI-guided laser interstitial thermal therapy (MRIg-LITT) thalamotomy for medically intractable ET. METHODS Nine patients with ET, unresponsive to medications and unsuitable for DBS, underwent unilateral MRIg-LITT thalamotomy. We assessed tremor severity, QOL, cognitive function, and adverse events (AE) over a 12-month period. RESULTS Tremor severity significantly improved, with a reduction of 83.37% at 12 months post-procedure. QOL scores improved by 74.60% at 12 months. Reported AEs predominantly included transient dysarthria, proprioceptive disturbances, and gait balance issues, which largely resolved within a month. At 3 months, 2 patients (22%) exhibited contralateral hemiparesis requiring physiotherapy, with 1 patient (11%) exhibiting persistent hemiparesis at 12 months. No significant cognitive impairment was detected post-procedure. CONCLUSIONS Unilateral MRIg-LITT thalamotomy yielded substantial and enduring tremor alleviation and enhanced QOL in patients with ET that is resistant to medication. The AE profile was acceptable. Our findings support the need for additional research with expanded patient cohorts and extended follow-up to corroborate these outcomes and to refine the role of MRIg-LITT as a targeted and minimally invasive approach for ET management. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Mickael Aubignat
- Department of Neurology and Movement Disorders, Amiens Picardie University Hospital, Amiens, France
- Expert Center for Parkinson's Disease, Amiens Picardie University Hospital, Amiens, France
| | - Mélissa Tir
- Department of Neurology and Movement Disorders, Amiens Picardie University Hospital, Amiens, France
- Expert Center for Parkinson's Disease, Amiens Picardie University Hospital, Amiens, France
| | - Martial Ouendo
- Expert Center for Parkinson's Disease, Amiens Picardie University Hospital, Amiens, France
- Department of Anaesthesiology and Critical Care Medicine, Amiens Picardie University Hospital, Amiens, France
| | - Salem Boussida
- Department of Radiology, Amiens Picardie University Hospital, Amiens, France
| | - Jean-Marc Constans
- Department of Radiology, Amiens Picardie University Hospital, Amiens, France
- Research Unit UR-7516 (CHIMERE) Research Team for Head & Neck, Institute Faire Faces, University of Picardie Jules Verne, Amiens, France
| | - Michel Lefranc
- Expert Center for Parkinson's Disease, Amiens Picardie University Hospital, Amiens, France
- Research Unit UR-7516 (CHIMERE) Research Team for Head & Neck, Institute Faire Faces, University of Picardie Jules Verne, Amiens, France
- Department of Neurosurgery, Amiens Picardie University Hospital, Amiens, France
- Research Unit in Robotic Surgery (GRECO), University of Picardie Jules Verne, Amiens, France
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Iorio-Morin C, Mathieu D, Franzini A, Hodaie M, Villeneuve SA, Hamel A, Lozano AM. Radiosurgical thalamotomy for essential tremor: state of the art, current challenges and future directions. Expert Rev Neurother 2024; 24:597-605. [PMID: 38713485 DOI: 10.1080/14737175.2024.2351512] [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: 03/08/2024] [Accepted: 05/01/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Essential tremor (ET) is the most frequent movement disorder, affecting up to 5% of adults > 65 years old. In 30-50% of cases, optimal medical management provides insufficient tremor relief and surgical options are considered. Thalamotomy is a time-honored intervention, which can be performed using radiofrequency (RF), stereotactic radiosurgery (SRS), or magnetic resonance-guided focused ultrasounds (MRgFUS). While the latter has received considerable attention in the last decade, SRS has consistently been demonstrated as an effective and well-tolerated option. AREAS COVERED This review discusses the evidence on SRS thalamotomy for ET. Modern workflows and emerging techniques are detailed. Current outcomes are analyzed, with a specific focus on tremor reduction, complications and radiological evolution of the lesions. Challenges for the field are highlighted. EXPERT OPINION SRS thalamotomy improves tremor in > 80% patients. The efficacy appears comparable to other modalities, including DBS, RF and MRgFUS. Side effects result mostly from idiosyncratic hyper-responses to radiation, which occur in up to 10% of treatments, are usually self-resolving, and are symptomatic in < 4% of patients. Future research should focus on accumulating more data on bilateral treatments, collecting long-term outcomes, refining targeting, and improving lesion consistency.
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Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, Canada
| | - David Mathieu
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, Canada
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Andréanne Hamel
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Ghimire S, Thapa B, Neupane D, Pokharel P. Outcomes of stereotactic thalamotomy in patients of essential tremor: A systematic review. J Clin Neurosci 2024; 126:38-45. [PMID: 38824802 DOI: 10.1016/j.jocn.2024.05.036] [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: 12/25/2023] [Revised: 05/18/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Essential tremor is a neurological condition associated with movement disorder with more prevalence among adult group of population. The burden of essential tremor is peaking globally but with the advancement in the area of functional neurosurgery such as stereotactic thalamotomy, the quality of life of such patients can be improved drastically. METHODS This systemic review was conducted in accordance to the guidance of preferred Reporting items for Systematic Review and Meta-Analysis(PRISMA). Databases of "PubMed", "Embase", "Web of Science", "Cinhal Plus", and "Scopus" from inception till 2023 was undertaken. A combination of keywords, Medical Subject Headings (MeSH), and search terms such as Search strategy for PubMed search was as follows: "stereotactic thalamotomy" AND "essential tremor". RESULTS This systematic review analyzed 9 studies with a total of 274 patients of essential tremor patients. Unilateral thalamotomy was carried out among 268 patients and bilateral thalamotomy in rest of the patients. Vim and Vom nucleus were the site of thalamotmy with ventral intermedius nucleus being the major one. Ten different types of clinical tremor rating scales were used to assess pre operative and post operative improvement in the tremor scales of the individual patients. Dysarthria and limb weakness was noted post operative complication in majority of the cases. CONCLUSION Our study revealed that stereotactic thalamotomy provided good functional outcome in patients of essential tremor who underwent unilateral thalamotomy compared to bilateral thalamotomy. The positive outcome outweighs the complications in such functional surgery.
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Affiliation(s)
- Sagun Ghimire
- Department of Neurosurgery, B and B Hospital, Gwarko, Lalitpur, Nepal.
| | - Bibechan Thapa
- Department of Surgery, West Hertfordshire Teaching Hospital, United Kingdom
| | - Durga Neupane
- B.P. Koirala Institute of Health Science, Dharan, Nepal
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Gautam D, Venkatraman V, Horns J, Yang LZ, Lee HJ, Kassavetis P, Alshaikh J, Moretti P, Shofty B, Rahimpour S. Demographics of focused ultrasound thalamotomy for essential tremor and trends in deep brain stimulation surgery after its introduction in the USA. BMJ Neurol Open 2024; 6:e000582. [PMID: 38618151 PMCID: PMC11015248 DOI: 10.1136/bmjno-2023-000582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 04/16/2024] Open
Abstract
Background Essential tremor (ET) is a movement disorder that affects 4%-5% of adults >65 years. For patients with medically refractory ET, neurosurgical interventions such as deep brain stimulation (DBS) and unilateral MR-guided focused ultrasound thalamotomy (MRgFUS) are available. In this retrospective cohort study, we examined the demographics of patients with ET who have received MRgFUS and evaluated trends in DBS usage in the USA after the introduction of MRgFUS in 2016. Methods We used multiple databases to examine the demographics of patients who received DBS and MRgFUS, and trends in DBS. To assess the demographics, we queried the TriNetX database from 2003 to 2022 to identify patients diagnosed with ET and stratify them by DBS or MRgFUS treatment by using Current Procedural Terminology codes. Patient demographics were reported as frequencies and percentages. To examine the trends in DBS for ET, the yearly frequency of DBS procedures done for ET between 2012 and 2019 was extracted from the National Inpatient Sample (NIS) database, and breakpoint analysis was performed. Additionally, the yearly frequency of MRgFUS procedures for ET was obtained from Insightec Exlabate. Results Most of the patients (88.69%) in the cohort extracted from TriNetX database self-identified as white, followed by black or African American (2.40%) and Asian (0.52%). A higher percentage of black patients received MRgFUS treatment than DBS (4.10% vs 1.88%). According to the NIS database, from 2012 to 2020, 13 525 patients received DBS for ET. Conclusion This study provides an overview of the characteristics of patients who undergo DBS or MRgFUS. We found notable differences in sex and race among patients who underwent each treatment type. Additionally, until at least the beginning of 2020, the number of DBS procedures for ET was not negatively affected after the introduction of MRgFUS.
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Affiliation(s)
- Diwas Gautam
- University of Utah Health, Salt Lake City, Utah, USA
| | | | - Joshua Horns
- Department of Surgery, Surgical Population Analysis Core, University of Utah Health, Salt Lake City, Utah, USA
| | - Lexie Zidanyue Yang
- Department of Biostatistics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jumana Alshaikh
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | - Paolo Moretti
- Department of Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | - Ben Shofty
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Shervin Rahimpour
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
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Bagarinao E, Maesawa S, Kato S, Mutoh M, Ito Y, Ishizaki T, Tanei T, Tsuboi T, Suzuki M, Watanabe H, Hoshiyama M, Isoda H, Katsuno M, Sobue G, Saito R. Cerebellar and thalamic connector hubs facilitate the involvement of visual and cognitive networks in essential tremor. Parkinsonism Relat Disord 2024; 121:106034. [PMID: 38382401 DOI: 10.1016/j.parkreldis.2024.106034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Connector hubs are specialized brain regions that connect multiple brain networks and therefore have the potential to affect the functions of multiple systems. This study aims to examine the involvement of connector hub regions in essential tremor. METHODS We examined whole-brain functional connectivity alterations across multiple brain networks in 27 patients with essential tremor and 27 age- and sex-matched healthy controls to identify affected hub regions using a network metric called functional connectivity overlap ratio estimated from resting-state functional MRI. We also evaluated the relationships of affected hubs with cognitive and tremor scores in all patients and with motor function improvement scores in 15 patients who underwent postoperative follow-up evaluations after focused ultrasound thalamotomy. RESULTS We have identified affected connector hubs in the cerebellum and thalamus. Specifically, the dentate nucleus in the cerebellum and the dorsomedial thalamus exhibited more extensive connections with the sensorimotor network in patients. Moreover, the connections of the thalamic pulvinar with the visual network were also significantly widespread in the patient group. The connections of these connector hub regions with cognitive networks were negatively associated (FDR q < 0.05) with cognitive, tremor, and motor function improvement scores. CONCLUSION In patients with essential tremor, connector hub regions within the cerebellum and thalamus exhibited widespread functional connections with sensorimotor and visual networks, leading to alternative pathways outside the classical tremor axis. Their connections with cognitive networks also affect patients' cognitive function.
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Affiliation(s)
- Epifanio Bagarinao
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan.
| | - Satoshi Maesawa
- Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan; Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Sachiko Kato
- Focused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital, Nagoya, Aichi, Japan
| | - Manabu Mutoh
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshiki Ito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Tomotaka Ishizaki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Tsuboi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masashi Suzuki
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hirohisa Watanabe
- Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan; Department of Neurology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Minoru Hoshiyama
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan
| | - Haruo Isoda
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan
| | - Masahisa Katsuno
- Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan; Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan; Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Gen Sobue
- Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan; Aichi Medical University, Nagakute, Aichi, Japan
| | - Ryuta Saito
- Brain and Mind Research Center, Nagoya University, Nagoya, Aichi, Japan; Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Zrinzo L. Severe Refractory Obsessive Compulsive Disorder and Depression: Should We Consider Stereotactic Neurosurgery? Neuropsychiatr Dis Treat 2024; 20:469-478. [PMID: 38463457 PMCID: PMC10921944 DOI: 10.2147/ndt.s407210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/22/2024] [Indexed: 03/12/2024] Open
Abstract
Functional neurosurgery involves modulation of activity within neural circuits that drive pathological activity. Neurologists and neurosurgeons have worked closely together, advancing the field for over a century, such that neurosurgical procedures for movement disorders are now accepted as "standard of care", benefiting hundreds of thousands of patients. As with movement disorders, some neuropsychiatric illnesses, including obsessive compulsive disorder and depression, can be framed as disorders of neural networks. Over the past two decades, evidence has accumulated that stereotactic neurosurgery can help some patients with mental disorders. Nevertheless, despite the availability of class I evidence for some interventions, there is a huge mismatch between the prevalence of severe refractory mental disorders and the number of referrals made to specialised functional neurosurgery services. This paper examines the historical trajectory of neurosurgery for movement and mental disorders. A review of neurosurgical techniques, including stereotactic radiofrequency ablation, gamma knife, deep brain stimulation, and magnetic resonance imaging guided focused ultrasound, explains the high degree of safety afforded by technological advances in the field. Evidence from clinical trials supporting functional neurosurgery for mental disorders, including obsessive compulsive disorder and depression, is presented. An improved understanding of modern functional neurosurgery should foster collaboration between psychiatry and neurosurgery, providing hope to patients whose symptoms are refractory to all other treatments.
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Affiliation(s)
- Ludvic Zrinzo
- Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, London, UK
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10
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Kesarwani R, Mahajan UV, Wang AS, Kilbane C, Shaikh AG, Miller JP, Sweet JA. Improved Side-Effect Stimulation Thresholds and Postoperative Transient Confusion With Asleep, Image-Guided Deep Brain Stimulation. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01042. [PMID: 38305427 DOI: 10.1227/ons.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/01/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Asleep, image-guided deep brain stimulation (DBS) is a modern alternative to awake, microelectrode recording (MER) guidance. Studies demonstrate comparable efficacy and complications between techniques, although some report lower stimulation thresholds for side effects with image guidance. In addition, few studies directly compare the risk of postoperative transient confusion (pTC) across techniques. The purpose of this study was to compare clinical efficacy, stimulation thresholds for side effects, and rates of pTC with MER-guided DBS vs intraoperative 3D-fluoroscopy (i3D-F) guidance in Parkinson's disease and essential tremor. METHODS Consecutive patients from 2006 to 2021 were identified from the departmental database and grouped as having either MER-guided DBS or i3D-F-guided DBS insertion. Directional leads were used once commercially available. Changes in Unified Parkinson's Disease Rating Scale (UPDRS)-III scores, levodopa equivalent daily dose, Fahn-Tolosa-Marin scores, and stimulation thresholds were assessed, as were rates of complications including pTC. RESULTS MER guidance was used to implant 487 electrodes (18 globus pallidus interna, GPi; 171 subthalamic nucleus; 76 ventrointermediate thalamus, VIM) in 265 patients. i3D-F guidance was used in 167 electrodes (19 GPi; 25 subthalamic nucleus; 41 VIM) in 85 patients. There were no significant differences in Unified Parkinson's Disease Rating III Scale, levodopa equivalent daily dose, or Fahn-Tolosa-Marin between groups. Stimulation thresholds for side effects were higher with i3D-F guidance in the subthalamic nucleus (MER, 2.80 mA ± 0.98; i3D-F, 3.46 mA ± 0.92; P = .002) and VIM (MER, 2.81 mA ± 1.00; i3D-F, 3.19 mA ± 1.03; P = .0018). Less pTC with i3D-F guidance (MER, 7.5%; i3D-F, 1.2%; P = .034) was also found. CONCLUSION Although clinical efficacy between MER-guided and i3D-F-guided DBS was comparable, thresholds for stimulation side effects were higher with i3D-F guidance and the rate of pTC was lower. This suggests that image-guided DBS may affect long-term side effects and pose a decreased risk of pTC.
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Affiliation(s)
- Rohit Kesarwani
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Current Affiliation: Meritas Health Neurosurgery, North Kansas City Hospital, North Kansas City, Missouri, USA
| | - Uma V Mahajan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Alexander S Wang
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Camilla Kilbane
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aasef G Shaikh
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- United States Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Jonathan P Miller
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer A Sweet
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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11
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Chagot C, Bustuchina Vlaicu M, Frismand S, Colnat-Coulbois S, Nguyen JP, Palfi S. Deep brain stimulation in multiple sclerosis-associated tremor. A large, retrospective, longitudinal open label study, with long-term follow-up. Mult Scler Relat Disord 2023; 79:104928. [PMID: 37657308 DOI: 10.1016/j.msard.2023.104928] [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: 09/23/2021] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Tremor affects up to 25%-58% in multiple sclerosis (MS) population. Deep-brain stimulation (DBS) of the ventral-intermediate nucleus (VIM) of the thalamus is considered as a potential option following medical treatments. Long term DBS efficacy is not well known in these patients with a poor outcome mostly related to disease progression. OBJECTIVE To report a large and retrospective study of thalamic DBS in MS tremor. METHODS We conducted a large and retrospective study of patients with MS disabling and pharmacologically resistant upper limb tremor, who underwent thalamic DBS procedure from January 1992 to January 2015 in University Hospital of Henri Mondor, France. Demographic data, clinical assessment and activity daily living were collected. A three-month and twelve-month post-operative assessment with clinical and functional rating scales have been achieved, as well as long term follow-up for most patients. RESULTS One hundred and four patients underwent DBS procedure. There were 71 female (68%) and 33 male (32%). At three-month post-operative assessment, 64% patients were improved clinically and functionally. Among these, 93% of patients kept a good efficacy at one-year post-operative assessment. Mean duration of follow-up for these patients was 6 years. CONCLUSION We described a long-term sustained clinical and functional improvement in this large and retrospective report of thalamic DBS. This neuromodulation approach could be a therapeutic option for all severe upper extremity refractory tremor in MS patients.
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Affiliation(s)
- Claire Chagot
- University Hospital of Nancy, Department of Neurology, 29 av Mar De Lattre de Tassigny, 54000 NANCY, France
| | - Mihaela Bustuchina Vlaicu
- Pitié Salpêtrière Hospital, Department of Neurosurgery, 83 Boulevard de l'Hôpital, Bâtiment Babinski, 75013, Paris, France; INSERM (National Institute of Health and Medical Research), U0955, Translational Neuro Psychiatry team, Avenue de Maréchal de Lattre de Tassigny, 94000, Créteil, France.
| | - Solène Frismand
- University Hospital of Nancy, Department of Neurology, 29 av Mar De Lattre de Tassigny, 54000 NANCY, France
| | - Sophie Colnat-Coulbois
- University Hospital of Nancy, Department of Neurosurgery, 29 av Mar De Lattre de Tassigny, 54000 NANCY, France
| | - Jean Paul Nguyen
- Department of Neurosurgery, Clinique Brétéché, Groupe Elsan, 3 Rue De La Béraudiere, 44046 Nantes, France
| | - Stéphane Palfi
- INSERM (National Institute of Health and Medical Research), U0955, Translational Neuro Psychiatry team, Avenue de Maréchal de Lattre de Tassigny, 94000, Créteil, France; Henri-Mondor Hospital, University Hospital APHP, Department of Neurosurgery, 51 AV Mar de Lattre de Tassigny, 94000 Créteil, France
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12
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Maragkos GA, Kosyakovsky J, Zhao P, Kearns KN, Rush-Evans S, Moosa S, Elias WJ. Patient-Reported Outcomes After Focused Ultrasound Thalamotomy for Tremor-Predominant Parkinson's Disease. Neurosurgery 2023; 93:884-891. [PMID: 37133259 DOI: 10.1227/neu.0000000000002518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 03/13/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) has emerged as a precise, incisionless approach to cerebral lesioning and an alternative to neuromodulation in movement disorders. Despite rigorous clinical trials, long-term patient-centered outcome data after MRgFUS for tremor-predominant Parkinson's Disease (TPPD) are relatively lacking. OBJECTIVE To report long-term data on patient satisfaction and quality of life after MRgFUS thalamotomy for TPPD. METHODS In a retrospective study of patients who underwent MRgFUS thalamotomy for TPPD at our institution between 2015 and 2022, a patient survey was administered to collect self-reported measures of tremor improvement, recurrence, Patients' Global Impression of Change (PGIC), and side effects. Patient demographics, FUS parameters, and lesion characteristics were analyzed. RESULTS A total of 29 patients were included with a median follow-up of 16 months. Immediate tremor improvement was achieved in 96% of patients. Sustained improvement was achieved in 63% of patients at last follow-up. Complete tremor recurrence to baseline occurred for 17% of patients. Life quality improvement denoted by a PGIC of 1 to 2 was reported by 69% of patients. Long-term side effects were reported by 38% of patients and were mostly mild. Performing a secondary anteromedial lesion to target the ventralis oralis anterior/posterior nucleus was associated with higher rates of speech-related side effects (56% vs 12%), without significant improvement in tremor outcomes. CONCLUSION Patient satisfaction with FUS thalamotomy for tremor-predominant PD was very high, even at longer term. Extended lesioning to target the motor thalamus did not improve tremor control and may contribute to greater frequency of postoperative motor- and speech-related side effects.
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Affiliation(s)
- Georgios A Maragkos
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Jacob Kosyakovsky
- University of Virginia School of Medicine, Charlottesville , Virginia , USA
| | - Patricia Zhao
- University of Virginia School of Medicine, Charlottesville , Virginia , USA
| | - Kathryn N Kearns
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Shelly Rush-Evans
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Shayan Moosa
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - W Jeffrey Elias
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
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Kumar A, Lin CC, Kuo SH, Pan MK. Physiological Recordings of the Cerebellum in Movement Disorders. CEREBELLUM (LONDON, ENGLAND) 2023; 22:985-1001. [PMID: 36070135 PMCID: PMC10354710 DOI: 10.1007/s12311-022-01473-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 06/15/2023]
Abstract
The cerebellum plays an important role in movement disorders, specifically in symptoms of ataxia, tremor, and dystonia. Understanding the physiological signals of the cerebellum contributes to insights into the pathophysiology of these movement disorders and holds promise in advancing therapeutic development. Non-invasive techniques such as electroencephalogram and magnetoencephalogram can record neural signals with high temporal resolution at the millisecond level, which is uniquely suitable to interrogate cerebellar physiology. These techniques have recently been implemented to study cerebellar physiology in healthy subjects as well as individuals with movement disorders. In the present review, we focus on the current understanding of cerebellar physiology using these techniques to study movement disorders.
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Affiliation(s)
- Ami Kumar
- Department of Neurology, Columbia University Irving Medical Center and the New York Presbyterian Hospital, 650 W 168thStreet, Room 305, New York, NY, 10032, USA
- Initiative for Columbia Ataxia and Tremor, Columbia University Irving Medical Center, New York, NY, USA
| | - Chih-Chun Lin
- Department of Neurology, Columbia University Irving Medical Center and the New York Presbyterian Hospital, 650 W 168thStreet, Room 305, New York, NY, 10032, USA
- Initiative for Columbia Ataxia and Tremor, Columbia University Irving Medical Center, New York, NY, USA
| | - Sheng-Han Kuo
- Department of Neurology, Columbia University Irving Medical Center and the New York Presbyterian Hospital, 650 W 168thStreet, Room 305, New York, NY, 10032, USA.
- Initiative for Columbia Ataxia and Tremor, Columbia University Irving Medical Center, New York, NY, USA.
| | - Ming-Kai Pan
- Cerebellar Research Center, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, 64041, Taiwan.
- Department and Graduate Institute of Pharmacology, National Taiwan University College of Medicine, Taipei, 10051, Taiwan.
- Department of Medical Research, National Taiwan University Hospital, Taipei, 10002, Taiwan.
- Institute of Biomedical Sciences, Academia Sinica, Taipei City, 11529, Taiwan.
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14
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Franz D, Richter A, Köhling R. Electrophysiological insights into deep brain stimulation of the network disorder dystonia. Pflugers Arch 2023; 475:1133-1147. [PMID: 37530804 PMCID: PMC10499667 DOI: 10.1007/s00424-023-02845-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 06/02/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
Deep brain stimulation (DBS), a treatment for modulating the abnormal central neuronal circuitry, has become the standard of care nowadays and is sometimes the only option to reduce symptoms of movement disorders such as dystonia. However, on the one hand, there are still open questions regarding the pathomechanisms of dystonia and, on the other hand, the mechanisms of DBS on neuronal circuitry. That lack of knowledge limits the therapeutic effect and makes it hard to predict the outcome of DBS for individual dystonia patients. Finding electrophysiological biomarkers seems to be a promising option to enable adapted individualised DBS treatment. However, biomarker search studies cannot be conducted on patients on a large scale and experimental approaches with animal models of dystonia are needed. In this review, physiological findings of deep brain stimulation studies in humans and animal models of dystonia are summarised and the current pathophysiological concepts of dystonia are discussed.
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Affiliation(s)
- Denise Franz
- Oscar Langendorff Institute of Physiology, University Medical Center Rostock, Rostock, Germany
| | - Angelika Richter
- Institute of Pharmacology, Pharmacy and Toxicology, University of Leipzig, Leipzig, Germany
| | - Rüdiger Köhling
- Oscar Langendorff Institute of Physiology, University Medical Center Rostock, Rostock, Germany.
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15
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Zeng J, Chu H, Lu Y, Xiao X, Lu L, Li J, Lai G, Li L, Lu L, Xu N, Wang S. Research status and hotspots in the surgical treatment of tremor in Parkinson's disease from 2002 to 2022: a bibliometric and visualization analysis. Front Aging Neurosci 2023; 15:1157443. [PMID: 37829141 PMCID: PMC10565824 DOI: 10.3389/fnagi.2023.1157443] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023] Open
Abstract
Objective This study aims to investigate the research status and hotspots of surgical treatment for tremor in Parkinson's disease (PD) from 2002 to 2022, utilizing bibliometric and visual analysis. Additionally, it aims to offer insights into future research trends in this field. Methods This study collected publications on the surgical treatment of tremor in PD from 2002 to 2022 using the Web of Science (WOS) database. CiteSpace, VOSviewer, and Scimago Graphica were employed to quantify the number of publications and analyze the bibliographic information networks, including the contributions of countries/cities, authors, keywords, and co-cited references. Results A total of 2,815 publications were included in the study, revealing that 541 scientific institutions experienced an increase in publications from 2002 to 2022. Michael Okun emerged as the most productive author, and the United States emerged as the leading hub for research. The study identified 772 keywords. Noteworthy citation bursts and long-term activity were observed in pallidotomy, bilateral stimulation, and focused ultrasound thalamotomy. The top 10 highly co-cited references comprised eight deep brain stimulation (DBS) studies (including two follow-up studies and six randomized controlled trials), one randomized controlled trial on focused ultrasound, and one consensus on tremor. Conclusion This study uses an in-depth and systematic bibliometric and visualization analysis to visualize the evolution of research and identify emerging hotspots. The identified hotspots are as follows: Firstly, DBS has received significant attention and widespread recognition as a surgical treatment for tremor in PD. Secondly, there are various key aspects to consider in DBS, such as operative indications, operative targets, and surgical protocols. Lastly, magnetic resonance-guided focused ultrasound (MRgFUS) has emerged as a promising treatment option in the surgical management of tremor in Parkinson's disease. This research also provides insights into the phenomenon of these hotspots, offering valuable prompts and reminders for further research.
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Affiliation(s)
- Jingchun Zeng
- Rehabilitation Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hui Chu
- The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yiqian Lu
- The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xi Xiao
- Rehabilitation Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Liming Lu
- Clinical Research and Data Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jingjing Li
- Bao’an Traditional Chinese Medicine Hospital, Seventh Clinical Medical College of Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Guoan Lai
- The First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lisha Li
- Xingtan Hospital, The Affiliated Shunde Hospital of Southern Medical University, Foshan, China
| | - Lihong Lu
- Rehabilitation Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nenggui Xu
- Clinical Research and Data Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuxin Wang
- Rehabilitation Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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16
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Smid A, Oterdoom DLM, Pauwels RWJ, Tamasi K, Elting JWJ, Absalom AR, van Laar T, van Dijk JMC, Drost G. The Relevance of Intraoperative Clinical and Accelerometric Measurements for Thalamotomy Outcome. J Clin Med 2023; 12:5887. [PMID: 37762828 PMCID: PMC10532071 DOI: 10.3390/jcm12185887] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/30/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Thalamotomy alleviates medication-refractory tremors in patients with movement disorders such as Parkinson's Disease (PD), Essential tremor (ET), and Holmes tremor (HT). However, limited data are available on tremor intensity during different thalamotomy stages. Also, the predictive value of the intraoperative tremor status for treatment outcomes remains unclear. Therefore, we aimed to quantify tremor status during thalamotomy and postoperatively. Data were gathered between January 2020 and June 2023 during consecutive unilateral thalamotomy procedures in patients with PD (n = 13), ET (n = 8), and HT (n = 3). MDS-UPDRS scores and tri-axial accelerometry data were obtained during rest, postural, and intention tremor tests. Measurements were performed intraoperatively (1) before lesioning-probe insertion, (2) directly after lesioning-probe insertion, (3) during coagulation, (4) directly after coagulation, and (5) 4-6 months post-surgery. Accelerometric data were recorded continuously during the coagulation process. Outcome measures included MDS-UPDRS tremor scores and accelerometric parameters (peak frequency, tremor amplitude, and area under the curve of power (AUCP)). Tremor intensity was assessed for the insertion effect (1-2), during coagulation (3), post-coagulation effect (1-4), and postoperative effect (1-5). Following insertion and coagulation, tremor intensity improved significantly compared to baseline (p < 0.001). The insertion effect clearly correlated with the postoperative effect (ρ = 0.863, p < 0.001). Both tremor amplitude and AUCP declined gradually during coagulation. Peak frequency did not change significantly intraoperatively. In conclusion, the study data show that both the intraoperative insertion effect and the post-coagulation effect are good predictors for thalamotomy outcomes.
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Affiliation(s)
- Annemarie Smid
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.L.M.O.); (R.W.J.P.); (K.T.); (J.M.C.v.D.); (G.D.)
| | - D. L. Marinus Oterdoom
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.L.M.O.); (R.W.J.P.); (K.T.); (J.M.C.v.D.); (G.D.)
| | - Rik W. J. Pauwels
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.L.M.O.); (R.W.J.P.); (K.T.); (J.M.C.v.D.); (G.D.)
| | - Katalin Tamasi
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.L.M.O.); (R.W.J.P.); (K.T.); (J.M.C.v.D.); (G.D.)
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jan Willem J. Elting
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (J.W.J.E.); (T.v.L.)
| | - Anthony R. Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Teus van Laar
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (J.W.J.E.); (T.v.L.)
| | - J. Marc C. van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.L.M.O.); (R.W.J.P.); (K.T.); (J.M.C.v.D.); (G.D.)
| | - Gea Drost
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.L.M.O.); (R.W.J.P.); (K.T.); (J.M.C.v.D.); (G.D.)
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (J.W.J.E.); (T.v.L.)
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17
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Franco G, Trujillo P, Lopez AM, Aumann MA, Englot DJ, Hainline A, Kang H, Konrad PE, Dawant BM, Claassen DO, Bick SK. Structural brain differences in essential tremor and Parkinson's disease deep brain stimulation patients. J Clin Neurosci 2023; 115:121-128. [PMID: 37549435 PMCID: PMC10530137 DOI: 10.1016/j.jocn.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Essential tremor (ET) and Parkinson's disease (PD) are the most common tremor disorders and are common indications for deep brain stimulation (DBS). In some patients, PD and ET symptoms overlap and diagnosis can be challenging based on clinical criteria alone. The objective of this study was to identify structural brain differences between PD and ET DBS patients to help differentiate these disorders and improve our understanding of the different brain regions involved in these pathologic processes. METHODS We included ET and PD patients scheduled to undergo DBS surgery in this observational study. Patients underwent 3T brain MRI while under general anesthesia as part of their procedure. Cortical thicknesses and subcortical volumes were quantified from T1-weighted images using automated multi-atlas segmentation. We used logistic regression analysis to identify brain regions associated with diagnosis of ET or PD. RESULTS 149 ET and 265 PD patients were included. Smaller volumes in the pallidum and thalamus and reduced thickness in the anterior orbital gyrus, lateral orbital gyrus, and medial precentral gyrus were associated with greater odds of ET diagnosis. Conversely, reduced volumes in the caudate, amygdala, putamen, and basal forebrain, and reduced thickness in the orbital part of the inferior frontal gyrus, supramarginal gyrus, and posterior cingulate were associated with greater odds of PD diagnosis. CONCLUSIONS These findings identify structural brain differences between PD and ET patients. These results expand our understanding of the different brain regions involved in these disorders and suggest that structural MRI may help to differentiate patients with these two disorders.
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Affiliation(s)
- Giulia Franco
- Department of Neurology, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA; IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Paula Trujillo
- Department of Neurology, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA.
| | - Alexander M Lopez
- Department of Neurology, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA.
| | - Megan A Aumann
- Department of Neurology, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA.
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA; Department of Biomedical Engineering, Vanderbilt University, 5824 Stevenson Center, Nashville, TN 37232, USA.
| | - Allison Hainline
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Ave, Nashville, TN 37203, USA
| | - Hakmook Kang
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Ave, Nashville, TN 37203, USA.
| | - Peter E Konrad
- Department of Neurosurgery, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA; Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, 33 Medical Center Drive, Morgantown, WV 26505, USA.
| | - Benoit M Dawant
- Department of Electrical and Computer Engineering, Vanderbilt University, PMB 351662, Nashville, TN 37235-1662, USA.
| | - Daniel O Claassen
- Department of Neurology, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA.
| | - Sarah K Bick
- Department of Neurosurgery, Vanderbilt University Medical Center, 1500 21st Avenue South, Nashville, TN 37232, USA; Department of Biomedical Engineering, Vanderbilt University, 5824 Stevenson Center, Nashville, TN 37232, USA; Department of Psychiatry, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA.
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Spampinato DA, Casula EP, Koch G. The Cerebellum and the Motor Cortex: Multiple Networks Controlling Multiple Aspects of Behavior. Neuroscientist 2023:10738584231189435. [PMID: 37649430 DOI: 10.1177/10738584231189435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
The cerebellum and its thalamic projections to the primary motor cortex (M1) are well known to play an essential role in executing daily actions. Anatomic investigations in animals and postmortem humans have established the reciprocal connections between these regions; however, how these pathways can shape cortical activity in behavioral contexts and help promote recovery in neuropathological conditions remains not well understood. The present review aims to provide a comprehensive description of these pathways in animals and humans and discuss how novel noninvasive brain stimulation (NIBS) methods can be used to gain a deeper understanding of the cerebellar-M1 connections. In the first section, we focus on recent animal literature that details how information sent from the cerebellum and thalamus is integrated into an broad network of cortical motor neurons. We then discuss how NIBS approaches in humans can be used to reliably assess the connectivity between the cerebellum and M1. Moreover, we provide the latest perspectives on using advanced NIBS approaches to investigate and modulate multiple cerebellar-cortical networks involved in movement behavior and plasticity. Finally, we discuss how these emerging methods have been used in translation research to produce long-lasting modifications of cerebellar-thalamic-M1 to restore cortical activity and motor function in neurologic patients.
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19
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Olivier C, Lamy JC, Kosutzka Z, Van Hamme A, Cherif S, Lau B, Vidailhet M, Karachi C, Welter ML. Cerebellar Transcranial Alternating Current Stimulation in Essential Tremor Patients with Thalamic Stimulation: A Proof-of-Concept Study. Neurotherapeutics 2023; 20:1109-1119. [PMID: 37097344 PMCID: PMC10457262 DOI: 10.1007/s13311-023-01372-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/26/2023] Open
Abstract
Essential tremor (ET) is a disabling condition resulting from a dysfunction of cerebello-thalamo-cortical circuitry. Deep brain stimulation (DBS) or lesion of the ventral-intermediate thalamic nucleus (VIM) is an effective treatment for severe ET. Transcranial cerebellar brain stimulation has recently emerged as a non-invasive potential therapeutic option. Here, we aim to investigate the effects of high-frequency non-invasive cerebellar transcranial alternating current stimulation (tACS) in severe ET patients already operated for VIM-DBS. Eleven ET patients with VIM-DBS, and 10 ET patients without VIM-DBS and matched for tremor severity, were included in this double-blind proof-of-concept controlled study. All patients received unilateral cerebellar sham-tACS and active-tACS for 10 min. Tremor severity was blindly assessed at baseline, without VIM-DBS, during sham-tACS, during and at 0, 20, 40 min after active-tACS, using kinetic recordings during holding posture and action ('nose-to-target') task and videorecorded Fahn-Tolosa-Marin (FTM) clinical scales. In the VIM-DBS group, active-tACS significantly improved both postural and action tremor amplitude and clinical (FTM scales) severity, relative to baseline, whereas sham-tACS did not, with a predominant effect for the ipsilateral arm. Tremor amplitude and clinical severity were also not significantly different between ON VIM-DBS and active-tACS conditions. In the non-VIM-DBS group, we also observed significant improvements in ipsilateral action tremor amplitude, and clinical severity after cerebellar active-tACS, with a trend for improved postural tremor amplitude. In non-VIM-DBS group, sham- active-tACS also decreased clinical scores. These data support the safety and potential efficacy of high-frequency cerebellar-tACS to reduce ET amplitude and severity.
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Affiliation(s)
- Claire Olivier
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France
| | - Jean-Charles Lamy
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France
- Department of Neurology, AP-HP, Hôpital Salpetriere, DMU Neuroscience 6, Paris, France
| | - Zuzana Kosutzka
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- Department of Neurology, AP-HP, Hôpital Salpetriere, DMU Neuroscience 6, Paris, France
| | - Angèle Van Hamme
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France
| | - Saoussen Cherif
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
| | - Brian Lau
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
| | - Marie Vidailhet
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- Department of Neurology, AP-HP, Hôpital Salpetriere, DMU Neuroscience 6, Paris, France
| | - Carine Karachi
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- Department of Neurosurgery, AP-HP, Hôpital Salpetriere, Paris, France
| | - Marie-Laure Welter
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France.
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France.
- Clinical Investigation Center, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France.
- Department of Neurophysiology, Rouen University Hospital, University of Rouen, Rouen, France.
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20
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Ferreira Felloni Borges Y, Cheyuo C, Lozano AM, Fasano A. Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound. Expert Rev Neurother 2023; 23:603-619. [PMID: 37288812 DOI: 10.1080/14737175.2023.2221789] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered. AREAS COVERED In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion. EXPERT OPINION DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.
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Affiliation(s)
- Yuri Ferreira Felloni Borges
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
- Department of Parkinson's Disease & Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital, Gravedona Ed Uniti, Como, Italy
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21
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Sato A, Taira T, Kitada K, Ando T, Hamaguchi T, Konno M, Kitabatake Y, Ishioka T. Displaced center of pressure on the treated side in individuals with essential tremor after radiofrequency ablation: a longitudinal case-control study. Front Neurol 2023; 14:1182082. [PMID: 37456636 PMCID: PMC10339740 DOI: 10.3389/fneur.2023.1182082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
Background Essential tremor (ET) is a common involuntary movement disorder (IMD). Radiofrequency ablation (RFA) targeting the ventral intermediate nucleus (Vim) of the thalamus is a stereotactic neurosurgery performed in individuals with ET when pharmacotherapy is no longer effective. Though the reasons remain largely unclear, certain adverse events are known to appear post-RFA. These may be due to functional changes in the Vim, related to RFA-induced tremor reduction, or an adverse reaction to compensatory movement patterns used to perform movements in the presence of tremor symptoms. Objective This study aimed to understand the characteristics of post-RFA symptoms in individuals with ET. Methods In a longitudinal case-control study, we compared post-RFA symptoms between individuals with ET who underwent Vim-targeted RFA and those with IMD who underwent non-Vim-targeted RFA. Symptoms were compared preoperatively and 1-week and 1-month postoperatively. Quantitative assessments included center-of-pressure (COP) parameters, grip strength, Mini-Mental State Examination, two verbal fluency tests, and three types of physical performance assessments (upper extremity ability, balance ability, and gait ability). Results Individuals with ET after RFA showed horizontal displacements of the COP to the treated side (the dominant side of the RFA target's hemisphere) at 1-week postoperatively compared to the preoperative period. The horizontal COP displacement was associated with balance dysfunction related to postural stability post-RFA. Other COP parameters did not significantly differ between the ET and IMD groups. Conclusion COP displacement to the treated side may be due to a time lag in adjusting postural holding strategies to the long-standing lateral difference in tremor symptoms associated with tremor improvement after RFA.
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Affiliation(s)
- Atsuya Sato
- Department of Occupational Therapy, School of Rehabilitation, Tokyo Professional University of Health Sciences, Tokyo, Japan
- Graduate School of Health and Social Services, Saitama Prefectural University, Saitama, Japan
- Department of Rehabilitation, Sanai Hospital, Saitama, Japan
| | - Takaomi Taira
- Department of Rehabilitation, Sanai Hospital, Saitama, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Kitada
- Department of Rehabilitation, Sanai Hospital, Saitama, Japan
| | - Toshiki Ando
- Department of Rehabilitation, Sanai Hospital, Saitama, Japan
| | - Toyohiro Hamaguchi
- Graduate School of Health and Social Services, Saitama Prefectural University, Saitama, Japan
| | - Michiko Konno
- Graduate School of Health and Social Services, Saitama Prefectural University, Saitama, Japan
| | - Yoshinori Kitabatake
- Graduate School of Health and Social Services, Saitama Prefectural University, Saitama, Japan
| | - Toshiyuki Ishioka
- Graduate School of Health and Social Services, Saitama Prefectural University, Saitama, Japan
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22
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Lueckel JM, Upadhyay N, Purrer V, Maurer A, Borger V, Radbruch A, Attenberger U, Wuellner U, Panda R, Boecker H. Whole-brain network transitions within the framework of ignition and transfer entropy following VIM-MRgFUS in essential tremor patients. Brain Stimul 2023; 16:879-888. [PMID: 37230462 DOI: 10.1016/j.brs.2023.05.006] [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: 10/28/2022] [Revised: 03/30/2023] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) lesioning of the ventralis intermedius nucleus (VIM) has shown promise in treating drug-refractory essential tremor (ET). It remains unknown whether focal VIM lesions by MRgFUS have broader restorative effects on information flow within the whole-brain network of ET patients. We applied an information-theoretical approach based on intrinsic ignition and the concept of transfer entropy (TE) to assess the spatiotemporal dynamics after VIM-MRgFUS. Eighteen ET patients (mean age 71.44 years) underwent repeated 3T resting-state functional magnetic resonance imaging combined with Clinical Rating Scale for Tremor (CRST) assessments one day before (T0) and one month (T1) and six months (T2) post-MRgFUS, respectively. We observed increased whole brain ignition-driven mean integration (IDMI) at T1 (p < 0.05), along with trend increases at T2. Further, constraining to motor network nodes, we identified significant increases in information-broadcasting (bilateral supplementary motor area (SMA) and left cerebellar lobule III) and information-receiving (right precentral gyrus) at T1. Remarkably, increased information-broadcasting in bilateral SMA was correlated with relative improvement of the CRST in the treated hand. In addition, causal TE-based effective connectivity (EC) at T1 showed an increase from right SMA to left cerebellar lobule crus II and from left cerebellar lobule III to right thalamus. In conclusion, results suggest a change in information transmission capacity in ET after MRgFUS and a shift towards a more integrated functional state with increased levels of global and directional information flow.
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Affiliation(s)
- Julia M Lueckel
- Clinical Functional Imaging Group, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany.
| | - Neeraj Upadhyay
- Clinical Functional Imaging Group, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Veronika Purrer
- German Center for Neurodegenerative Diseases, Bonn, Germany; Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Angelika Maurer
- Clinical Functional Imaging Group, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Alexander Radbruch
- German Center for Neurodegenerative Diseases, Bonn, Germany; Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Ulrike Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Ullrich Wuellner
- German Center for Neurodegenerative Diseases, Bonn, Germany; Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Rajanikant Panda
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Henning Boecker
- Clinical Functional Imaging Group, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany; German Center for Neurodegenerative Diseases, Bonn, Germany.
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23
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Hariz M. Pros and Cons of Ablation for Functional Neurosurgery in the Neurostimulation Age. Neurosurg Clin N Am 2023; 34:291-299. [PMID: 36906335 DOI: 10.1016/j.nec.2022.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Should one recommend stereotactic ablation for Parkinson disease, tremor, dystonia, and obsessive compulsive disorder, in this era of DBS? The answer depends on several variables such as the symptoms to treat, the patient's preferences and expectations, the surgeons' competence and preference, the availability of financial means (by government health care, by private insurance), the geographical issues, and not least the current and dominating fashion at that particular time. Both ablation and stimulation can be either used alone or even combined (provided expertise in both of them) to treat various symptoms of movement and mind disorders.
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Affiliation(s)
- Marwan Hariz
- Department of Clinical Neuroscience, University Hospital, Umeå 90185, Sweden.
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24
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Swytink-Binnema CA, Rockel CP, Martino D, Dukelow SP, Pike GB, Kiss ZHT. Limb Preference Changes after Focused-Ultrasound Thalamotomy for Tremor. Mov Disord 2023. [PMID: 36947685 DOI: 10.1002/mds.29350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Magnetic resonance-guided focused-ultrasound (MRgFUS) thalamotomy is an effective treatment for essential and other tremors. It targets the ventrointermedius (Vim) nucleus, which is the thalamic relay in a proprioceptive pathway, and contains kinesthetic cells. Although MRgFUS thalamotomy reduces some risks associated with more invasive surgeries, it still has side effects, such as balance and gait disturbances; these may be caused by the lesion impacting proprioception. OBJECTIVES Our aim was to quantitatively measure the effects of MRgFUS on proprioception and limb use in essential tremor patients. We hypothesized that this thalamotomy alters proprioception, because the sensorimotor Vim thalamus is lesioned. METHODS Proprioception was measured using the Kinarm exoskeleton robot in 18 patients. Data were collected pre-operatively, and then 1 day, 3 months, and 1 year after surgery. Patients completed four tasks, assessing motor coordination and postural control, goal-directed movement and bimanual planning, position sense, and kinesthesia. RESULTS Immediately after surgery there were changes in posture speed (indicating tremor improvement), and in bimanual hand use, with the untreated limb being preferred. However, these measures returned to pre-operative baseline over time. There were no changes in parameters related to proprioception. None of these measures correlated with lesion size or lesion-overlap with the dentato-rubro-thalamic tract. CONCLUSIONS This is the first quantitative assessment of proprioception and limb preference following MRgFUS thalamotomy. Our results suggest that focused-ultrasound lesioning of the Vim thalamus does not degrade proprioception but alters limb preference. This change may indicate a required "relearning" in the treated limb, because the effect is transient. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Catherine A Swytink-Binnema
- Department of Biomedical Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Conrad P Rockel
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean P Dukelow
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - G Bruce Pike
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zelma H T Kiss
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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25
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Dardiotis E, Skouras P, Varvarelis OP, Aloizou AM, Hernández AF, Liampas I, Rikos D, Dastamani M, Golokhvast KS, Bogdanos DP, Tsatsakis A, Siokas V, Mitsias PD, Hadjigeorgiou GM. Pesticides and tremor: An overview of association, mechanisms and confounders. ENVIRONMENTAL RESEARCH 2023; 229:115442. [PMID: 36758916 DOI: 10.1016/j.envres.2023.115442] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 05/06/2023]
Abstract
Pesticides are a heterogeneous class of chemicals mainly used for the protection of crops from pests. Because of their very widespread use, acute or/and chronic exposure to these chemicals can lead to a plethora of sequelae inflicting diseases, many of which involve the nervous system. Tremor has been associated with pesticide exposure in human and animal studies. This review is aimed at assessing the studies currently available on the association between the various types of pesticides/insecticides and tremor, while also accounting for potential confounding factors. To our knowledge, this is the first coherent review on the subject. After appraising the available evidence, we call for more intensive research on this topic, as well as intonate the need of implementing future preventive measures to protect the exposed populations and to reduce potential disabilities and social drawbacks.
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Affiliation(s)
- Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Panagiotis Skouras
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Orfeas-Petros Varvarelis
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athina-Maria Aloizou
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Antonio F Hernández
- Department of Legal Medicine and Toxicology, University of Granada School of Medicine, Granada, Spain; Health Research Institute of Granada (ibs.GRANADA), Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Ioannis Liampas
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Rikos
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Metaxia Dastamani
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Kirill S Golokhvast
- Siberian Federal Scientific Center of Agrobiotechnology RAS, Krasnoobsk, Russia, 630501
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Aristidis Tsatsakis
- Center of Toxicology Science & Research, Medical School, University of Crete, 71003, Heraklion, Crete, Greece
| | - Vasileios Siokas
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Panayiotis D Mitsias
- Department of Neurology, School of Medicine, University of Crete, 71003, Heraklion, Greece; Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Georgios M Hadjigeorgiou
- Department of Neurology, University Hospital of Larissa Greece, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology, Medical School, University of Cyprus, Nicosia, Cyprus
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26
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Pirker W, Katzenschlager R, Hallett M, Poewe W. Pharmacological Treatment of Tremor in Parkinson's Disease Revisited. JOURNAL OF PARKINSON'S DISEASE 2023; 13:127-144. [PMID: 36847017 PMCID: PMC10041452 DOI: 10.3233/jpd-225060] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The pathophysiology of Parkinson's disease (PD) tremor remains incompletely understood and there is a lack of clinical trials specifically addressing its pharmacological treatment. Levodopa is the most efficacious drug for most patients and should be used as primary approach to control troublesome tremor. While the efficacy of oral dopamine agonists on PD tremor has been demonstrated in controlled trials, there is no evidence of greater antitremor efficacy compared to levodopa. The magnitude of the antitremor effect of anticholinergics is generally lower than that of levodopa. Due to their adverse effects, anticholinergics have a limited role in selected young and cognitively intact patients. Propranolol may improve resting and action tremor and may be considered as an adjunct in patients with insufficient tremor response to levodopa and this also applies to clozapine, despite its unfavorable adverse effect profile. Treating motor fluctuations with MAO-B and COMT inhibitors, dopamine agonists, amantadine, or on-demand treatments such as subcutaneous or sublingual apomorphine and inhaled levodopa as well as with continuous infusions of levodopa or apomorphine will improve off period tremor episodes. For patients with drug-refractory PD tremor despite levodopa optimization deep brain stimulation and focused ultrasound are first-line considerations. Surgery can also be highly effective for the treatment medication-refractory tremor in selected patients without motor fluctuations. The present review highlights the clinical essentials of parkinsonian tremor, critically examines available trial data on the effects of medication and surgical approaches and provides guidance for the choice of treatments to control PD tremor in clinical practice.
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Affiliation(s)
- Walter Pirker
- Department of Neurology, Klinik Ottakring, Vienna, Austria
| | - Regina Katzenschlager
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Klinik Donaustadt, Vienna, Austria
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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27
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Louis ED. Essential tremor. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:389-401. [PMID: 37620080 DOI: 10.1016/b978-0-323-98817-9.00012-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Essential tremor (ET) is a chronic and progressive neurologic disease. Its central and defining clinical feature is a 4-12Hz kinetic tremor, that is, tremor that occurs during voluntary movements such as drinking from a cup or writing. Patients may also exhibit a range of other tremors-postural, rest, intention, additional motor features (e.g., mild gait ataxia, mild dystonia), as well as nonmotor features. The disease itself seems to be a risk factor for other degenerative diseases such as Alzheimer's disease and Parkinson's disease. Both genetic and toxic environmental factors have been explored as etiologic factors. In addition to a growing appreciation of the presence of clinical, etiologic, and pathologic heterogeneity, there is some support for the notion that ET itself may not be a single disease, but may be a family of diseases whose central defining feature is kinetic tremor of the arms, and which might more accurately be referred to as "the essential tremors." Recent research has increasingly placed the seat of the disease in the cerebellum and cerebellar system and identified a host of neurodegenerative changes within the cerebellum, indicating that this progressive disorder is likely degenerative.
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Affiliation(s)
- Elan D Louis
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States.
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28
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Zhou J, Van der Heijden ME, Salazar Leon LE, Lin T, Miterko LN, Kizek DJ, Perez RM, Pavešković M, Brown AM, Sillitoe RV. Propranolol Modulates Cerebellar Circuit Activity and Reduces Tremor. Cells 2022; 11:cells11233889. [PMID: 36497147 PMCID: PMC9740691 DOI: 10.3390/cells11233889] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/10/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Tremor is the most common movement disorder. Several drugs reduce tremor severity, but no cures are available. Propranolol, a β-adrenergic receptor blocker, is the leading treatment for tremor. However, the in vivo circuit mechanisms by which propranolol decreases tremor remain unclear. Here, we test whether propranolol modulates activity in the cerebellum, a key node in the tremor network. We investigated the effects of propranolol in healthy control mice and Car8wdl/wdl mice, which exhibit pathophysiological tremor and ataxia due to cerebellar dysfunction. Propranolol reduced physiological tremor in control mice and reduced pathophysiological tremor in Car8wdl/wdl mice to control levels. Open field and footprinting assays showed that propranolol did not correct ataxia in Car8wdl/wdl mice. In vivo recordings in awake mice revealed that propranolol modulates the spiking activity of control and Car8wdl/wdl Purkinje cells. Recordings in cerebellar nuclei neurons, the targets of Purkinje cells, also revealed altered activity in propranolol-treated control and Car8wdl/wdl mice. Next, we tested whether propranolol reduces tremor through β1 and β2 adrenergic receptors. Propranolol did not change tremor amplitude or cerebellar nuclei activity in β1 and β2 null mice or Car8wdl/wdl mice lacking β1 and β2 receptor function. These data show that propranolol can modulate cerebellar circuit activity through β-adrenergic receptors and may contribute to tremor therapeutics.
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Affiliation(s)
- Joy Zhou
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Meike E. Van der Heijden
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
| | - Luis E. Salazar Leon
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Tao Lin
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
| | - Lauren N. Miterko
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
- Program in Development, Disease Models & Therapeutics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Dominic J. Kizek
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
| | - Ross M. Perez
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
- Program in Development, Disease Models & Therapeutics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Matea Pavešković
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Amanda M. Brown
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
| | - Roy V. Sillitoe
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, 1250 Moursund Street, Suite 1325, Houston, TX 77030, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
- Program in Development, Disease Models & Therapeutics, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-832-824-8913
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29
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Petersen JJ, Juul S, Jørgensen CK, Gluud C, Jakobsen JC. Deep brain stimulation for neurological disorders: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials. Syst Rev 2022; 11:218. [PMID: 36229825 PMCID: PMC9558400 DOI: 10.1186/s13643-022-02095-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 10/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Deep brain stimulation has been used since the 1980s for neurological disorders and the USA and Europe have now approved it for Parkinson's disease, essential tremor, dystonia, and epilepsy. Previous reviews have assessed the effects of deep brain stimulation on different neurological disorders. These reviews all had methodological limitations. METHODS This is a protocol for a systematic review based on searches of major medical databases (e.g. MEDLINE, EMBASE, CENTRAL) and clinical trial registries. Two review authors will independently extract data and conduct risk of bias assessment. We will include published and unpublished randomised clinical trial comparing deep brain stimulation versus no intervention, usual care, sham stimulation, medical treatment, or resective surgery for Parkinson's disease, essential tremor, dystonia, or epilepsy. The effects of deep brain stimulation will be analysed separately for each of the different diagnoses. Primary outcomes will be all-cause mortality, disease-specific symptoms, and serious adverse events. Secondary outcomes will be quality of life, depressive symptoms, executive functioning, level of functioning, and non-serious adverse events. Data will be analysed using fixed-effect and random-effects meta-analyses and Trial Sequential Analysis. Risk of bias will be assessed with the Cochrane Risk of Bias tool-version 2, an eight-step procedure to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed by Grading of Recommendations, Assessment, Development and Evaluations (GRADE). DISCUSSION Deep brain stimulation is increasingly being used for different neurological diseases, and the effects are unclear based on previous evidence. There is a need for a comprehensive systematic review of the current evidence. This review will provide the necessary background for weighing the benefits against the harms when assessing deep brain stimulation as intervention for individual neurological disorders. SYSTEMATIC REVIEW REGISTRATION PROSPERO 306,556.
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Affiliation(s)
- Johanne Juul Petersen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen Ø, 2100, Copenhagen, Denmark.
| | - Sophie Juul
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen Ø, 2100, Copenhagen, Denmark
| | - Caroline Kamp Jørgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen Ø, 2100, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen Ø, 2100, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, Odense C, 5000, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen Ø, 2100, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, Odense C, 5000, Odense, Denmark
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30
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Yamamoto K, Sarica C, Loh A, Vetkas A, Samuel N, Milano V, Zemmar A, Germann J, Cheyuo C, Boutet A, Elias GJ, Ito H, Taira T, Lozano AM. Magnetic resonance-guided focused ultrasound for the treatment of tremor. Expert Rev Neurother 2022; 22:849-861. [PMID: 36469578 DOI: 10.1080/14737175.2022.2147826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Magnetic resonance-guided focused ultrasound (MRgFUS) is an emerging treatment for tremor and other movement disorders. An incisionless therapy, it is becoming increasingly common worldwide. However, given MRgFUS' relative novelty, there remain limited data on its benefits and adverse effects. AREAS COVERED We review the current state of evidence of MRgFUS for tremor, highlight its challenges, and discuss future perspectives. EXPERT OPINION Essential tremor (ET) has been the major indication for MRgFUS since a milestone randomized controlled trial (RCT) in 2016, with substantial evidence attesting to the efficacy and acceptable safety profile of this treatment. Patients with other tremor etiologies are also being treated with MRgFUS, with studies - including an RCT - suggesting parkinsonian tremor in particular responds well to this intervention. Additionally, targets other than the ventral intermediate nucleus, such as the subthalamic nucleus and internal segment of the globus pallidus, have been reported to improve parkinsonian symptoms beyond tremor, including rigidity and bradykinesia. Although MRgFUS is encumbered by certain unique technical challenges, it nevertheless offers significant advantages compared to alternative neurosurgical interventions for tremor. The fast-growing interest in this treatment modality will likely lead to further scientific and technological advancements that could optimize and expand its therapeutic potential.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Artur Vetkas
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Department of Neurosurgery, School of Medicine, University of Tartu, Estonia
| | - Nardin Samuel
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Vanessa Milano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, School of Medicine, KY, USA.,Department of Neurosurgery, Henan University People's Hospital, Henan University School of Medicine, China
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Gavin Jb Elias
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Hisashi Ito
- Department of Neurology, Shonantobu General Hospital, Japan.,Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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Parras O, Domínguez P, Tomás-Biosca A, Guridi J. The role of tractography in the localization of the Vim nucleus of the thalamus and the dentato-rubro-thalamic tract for the treatment of tremor. Neurologia 2022; 37:691-699. [PMID: 31917004 DOI: 10.1016/j.nrl.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/08/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION The ventralis intermedius (Vim) nucleus of the thalamus is the usual surgical target for tremor. However, locating the structure may be difficult as it is not visible with conventional imaging methods; therefore, surgical procedures typically use indirect calculations correlated with clinical and intraoperative neurophysiological findings. Current ablative surgical procedures such as Gamma-Knife thalamotomy and magnetic resonance-guided focused ultrasound require new alternatives for locating the Vim nucleus. In this review, we compare Vim nucleus location for the treatment of tremor using stereotactic procedures versus direct location by means of tractography. DISCUSSION The most widely used cytoarchitectonic definition of the Vim nucleus is that established by Schaltenbrand and Wahren. There is a well-defined limit between the motor and the sensory thalamus; Vim neurons respond to passive joint movements and are synchronous with peripheral tremor. The most frequently used stereotactic coordinates for the Vim nucleus are based on indirect calculations referencing the mid-commissural line and third ventricle, which vary between patients. Recent studies suggest that the dentato-rubro-thalamic tract is an optimal target for controlling tremor, citing a clinical improvement; however, this has not yet been corroborated. CONCLUSIONS Visualisation of the cerebello-rubro-thalamic pathway by tractography may help in locating the Vim nucleus. The technique has several limitations, and the method requires standardisation to obtain more precise results. The utility of direct targeting by tractography over indirect targeting for patients with tremor remains to be demonstrated in the long-term.
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Affiliation(s)
- O Parras
- Servicio de Neurocirugía, Clínica Universidad de Navarra, Pamplona, España
| | - P Domínguez
- Servicio de Neurorradiología, Clínica Universidad de Navarra, Pamplona, España
| | - A Tomás-Biosca
- Servicio de Neurocirugía, Clínica Universidad de Navarra, Pamplona, España
| | - J Guridi
- Servicio de Neurocirugía, Clínica Universidad de Navarra, Pamplona, España.
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32
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Fejeran J, Salazar F, Alvarez CM, Jahangiri FR. Deep Brain Stimulation and Microelectrode Recording for the Treatment of Parkinson’s Disease. Cureus 2022; 14:e27887. [PMID: 36110462 PMCID: PMC9464012 DOI: 10.7759/cureus.27887] [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] [Accepted: 08/11/2022] [Indexed: 11/05/2022] Open
Abstract
Parkinson’s disease (PD) is a neurological disorder in which nigrostriatal pathways involving the basal ganglia experience a decrease in neural activity regarding dopaminergic neurons. PD symptoms, such as muscle stiffness and involuntary tremors, have an adverse impact on the daily lives of those affected. Current medical treatments seek to decrease the severity of these symptoms. Deep brain stimulation (DBS) has become the preferred safe, and reliable treatment approach. DBS involves implanting microelectrodes into subcortical areas that produce electrical impulses directly to high populations of dopaminergic neurons. The most common targets are the subthalamic nucleus (STN), and the basal ganglia's globus pallidus pars interna (GPi). Research studies suggest that DBS of the STN may cause a significant reduction in the daily dose of L-DOPA compared to DBS of the GPi. DBS of the STN has suggested that there may be sweet spots within the STN that provide hyper-direct cortical connectivity pathways to the primary motor cortex (M1), supplementary motor area (SMA), and prefrontal cortex (PFC). In addition, the pedunculopontine nucleus (PPN) may be a new target for DBS that helps treat locomotion problems associated with gait and posture. Both microelectrode recording (MER) and magnetic resonance imaging (MRI) are used to ensure electrode placement accuracy. Using MER, stimulation of the STN at high frequencies (140<) decreased oscillatory neuronal firing by 67%. This paper investigates methods of intraoperative neuromonitoring during DBS as a form of PD treatment.
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33
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Deuschl G, Antonini A, Costa J, Śmiłowska K, Berg D, Corvol J, Fabbrini G, Ferreira J, Foltynie T, Mir P, Schrag A, Seppi K, Taba P, Ruzicka E, Selikhova M, Henschke N, Villanueva G, Moro E. European Academy of Neurology/Movement Disorder Society ‐ European Section guideline on the treatment of Parkinson's disease: I. Invasive therapies. Eur J Neurol 2022; 29:2580-2595. [DOI: 10.1111/ene.15386] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Günther Deuschl
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience University of Padua Padua Italy
| | - Joao Costa
- Faculdade de Medicina da Universidade de Lisboa Lisbon Portugal
| | - Katarzyna Śmiłowska
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Daniela Berg
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Jean‐Christophe Corvol
- Institut du Cerveau–Paris Brain Institute Assistance Publique Hôpitaux de Paris Pitié‐Salpêtrière Hospital Department of Neurology, Centre d'Investigation Clinique Neurosciences Sorbonne Université Paris France
| | - Giovanni Fabbrini
- Department Human Neurosciences Sapienza University of Rome Rome Italy
- Neuromed Rome Italy
| | - Joaquim Ferreira
- Faculdade de Medicina Universidade de Lisboa Lisbon Portugal
- Instituto de Medicina Molecular João Lobo Antunes Lisbon Portugal
- Campus Neurológico Torres Vedras Portugal
| | - Tom Foltynie
- Department of Clinical & Movement Neurosciences Institute of Neurology London UK
| | - Pablo Mir
- Unidad de Trastornos del Movimiento Servicio de Neurología y Neurofisiología Clínica Instituto de Biomedicina de Sevilla Hospital Universitario Virgen del Rocío/Universidad de Sevilla Seville Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas Madrid Spain
- Departamento de Medicina Facultad de Medicina Universidad de Sevilla Seville Spain
| | - Annette Schrag
- Institute of Neurology, University Clinic London London UK
| | - Klaus Seppi
- Klinik f. Neurologie Medizinische Universität Innsbruck Innsbruck Austria
| | - Pille Taba
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine University of Tartu Tartu Estonia
- Tartu University Hospital Tartu Estonia
| | - Evzen Ruzicka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czechia
| | - Marianna Selikhova
- Department of Neurology Pirogov Russian National Research Medical University Moscow Russia
| | | | | | - Elena Moro
- Division of Neurology, Grenoble, Grenoble Institute of Neurosciences Grenoble Alpes University Grenoble France
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34
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Deuschl G, Antonini A, Costa J, Śmiłowska K, Berg D, Corvol J, Fabbrini G, Ferreira J, Foltynie T, Mir P, Schrag A, Seppi K, Taba P, Ruzicka E, Selikhova M, Henschke N, Villanueva G, Moro E. European Academy of Neurology/Movement Disorder Society‐European Section Guideline on the Treatment of Parkinson's Disease: I. Invasive Therapies. Mov Disord 2022; 37:1360-1374. [DOI: 10.1002/mds.29066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Affiliation(s)
- Günther Deuschl
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience University of Padua Padua Italy
| | - Joao Costa
- Faculdade de Medicina da Universidade de Lisboa Lisbon Portugal
| | - Katarzyna Śmiłowska
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Daniela Berg
- Department of Neurology, UKSH‐Kiel Campus Christian‐Albrechts‐University Kiel Germany
| | - Jean‐Christophe Corvol
- Institut du Cerveau‐Paris Brain Institute, Assistance Publique Hôpitaux de Paris, Pitié‐Salpêtrière Hospital, Department of Neurology, Centre d'Investigation Clinique Neurosciences Sorbonne Université Paris France
| | - Giovanni Fabbrini
- Department Human Neurosciences Sapienza University of Rome Rome Italy
- IRCCS Neuromed Rome Italy
| | - Joaquim Ferreira
- Faculdade de Medicina Universidade de Lisboa Lisbon Portugal
- Instituto de Medicina Molecular João Lobo Antunes Lisbon Portugal
- Campus Neurológico Torres Vedras Portugal
| | - Tom Foltynie
- Department of Clinical & Movement Neurosciences Institute of Neurology London UK
| | - Pablo Mir
- Unidad de Trastornos del Movimiento Servicio de Neurología y Neurofisiología Clínica Instituto de Biomedicina de Sevilla Hospital Universitario Virgen del Rocío/Universidad de Sevilla Seville Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas Madrid Spain
- Departamento de Medicina Facultad de Medicina Universidad de Sevilla Seville Spain
| | - Annette Schrag
- Institute of Neurology, University Clinic London London UK
| | - Klaus Seppi
- Klinik f. Neurologie Medizinische Universität Innsbruck Innsbruck Austria
| | - Pille Taba
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine University of Tartu Tartu Estonia
- Tartu University Hospital Tartu Estonia
| | - Evzen Ruzicka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine Charles University and General University Hospital in Prague Prague Czechia
| | | | | | | | - Elena Moro
- Division of Neurology, Grenoble, Grenoble Institute of Neurosciences Grenoble Alpes University Grenoble France
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35
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Overnight unilateral withdrawal of thalamic deep brain stimulation to identify reversibility of gait disturbances. Exp Neurol 2022; 355:114135. [DOI: 10.1016/j.expneurol.2022.114135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/11/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022]
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36
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Tani N, Oshino S, Hosomi K, Hattori N, Mihara M, Yanagisawa T, Khoo HM, Kanemoto M, Watanabe Y, Mochizuki H, Kishima H. Altered Thalamic Connectivity Due to Focused Ultrasound Thalamotomy in Patients with Essential Tremor. World Neurosurg 2022; 164:e1103-e1110. [PMID: 35660481 DOI: 10.1016/j.wneu.2022.05.113] [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: 04/23/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although stereotactic ablation surgery is known to ameliorate involuntary movement dramatically, little is known regarding alterations in whole-brain networks due to disruption of the deep brain nucleus. To explore changes in the whole-brain network after thalamotomy, we analyzed structural and functional connectivity alterations using resting-state functional magnetic resonance imaging and diffusion tensor imaging in patients with essential tremor who had undergone focused ultrasound (FUS) thalamotomy. METHODS Seven patients with intractable essential tremors and 7 age-matched healthy controls were enrolled in the study. The tremor score in essential tremor patients was assessed, and resting-state functional magnetic resonance imaging and diffusion tensor imaging were performed before and 3 months after left ventral intermediate nucleus thalamotomy using FUS. RESULTS There was a significant improvement in the tremor of the right hand after FUS thalamotomy. Seed-based functional connectivity analysis revealed a significant increase in functional connectivity between the left thalamus and the caudal part of the dorsal premotor cortex after FUS thalamotomy. Structural connectivity analysis did not detect statistically significant changes between before and after FUS. There was no correlation between the changes in functional connectivity and tremor score. CONCLUSIONS Although the number of cases is small, our results show that functional connectivity between the thalamus and the premotor cortex increases after the amelioration of tremors by FUS thalamotomy. The lack of correlation between increased functional connectivity and clinical tremor scores suggests that the observed increase in functional connectivity may be a compensatory change in the secondary sensorimotor changes that occur after thalamotomy.
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Affiliation(s)
- Naoki Tani
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Satoru Oshino
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koichi Hosomi
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Hattori
- Department of Rehabilitation, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Masahito Mihara
- Department of Neurology, Kawasaki Medical University, Kurashiki, Japan
| | - Takufumi Yanagisawa
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hui Ming Khoo
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Manabu Kanemoto
- Department of Neurosurgery, Saito Yukokai Hospital, Ibaraki, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
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37
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Baek H, Lockwood D, Mason EJ, Obusez E, Poturalski M, Rammo R, Nagel SJ, Jones SE. Clinical Intervention Using Focused Ultrasound (FUS) Stimulation of the Brain in Diverse Neurological Disorders. Front Neurol 2022; 13:880814. [PMID: 35614924 PMCID: PMC9124976 DOI: 10.3389/fneur.2022.880814] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Various surgical techniques and pharmaceutical treatments have been developed to improve the current technologies of treating brain diseases. Focused ultrasound (FUS) is a new brain stimulation modality that can exert a therapeutic effect on diseased brain cells, with this effect ranging from permanent ablation of the pathological neural circuit to transient excitatory/inhibitory modulation of the neural activity depending on the acoustic energy of choice. With the development of intraoperative imaging technology, FUS has become a clinically available noninvasive neurosurgical option with visual feedback. Over the past 10 years, FUS has shown enormous potential. It can deliver acoustic energy through the physical barrier of the brain and eliminate abnormal brain cells to treat patients with Parkinson's disease and essential tremor. In addition, FUS can help introduce potentially beneficial therapeutics at the exact brain region where they need to be, bypassing the brain's function barrier, which can be applied for a wide range of central nervous system disorders. In this review, we introduce the current FDA-approved clinical applications of FUS, ranging from thermal ablation to blood barrier opening, as well as the emerging applications of FUS in the context of pain control, epilepsy, and neuromodulation. We also discuss the expansion of future applications and challenges. Broadening FUS technologies requires a deep understanding of the effect of ultrasound when targeting various brain structures in diverse disease conditions in the context of skull interface, anatomical structure inside the brain, and pathology.
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Affiliation(s)
- Hongchae Baek
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Daniel Lockwood
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Emmanuel Obusez
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Stephen E. Jones
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- *Correspondence: Stephen E. Jones
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Movement Disorders in Multiple Sclerosis: An Update. Tremor Other Hyperkinet Mov (N Y) 2022; 12:14. [PMID: 35601204 PMCID: PMC9075048 DOI: 10.5334/tohm.671] [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: 11/13/2021] [Accepted: 04/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Multiple sclerosis (MS), a subset of chronic primary inflammatory demyelinating disorders of the central nervous system, is closely associated with various movement disorders. These disorders may be due to MS pathophysiology or be coincidental. This review describes the full spectrum of movement disorders in MS with their possible mechanistic pathways and therapeutic modalities. Methods: The authors conducted a narrative literature review by searching for ‘multiple sclerosis’ and the specific movement disorder on PubMed until October 2021. Relevant articles were screened, selected, and included in the review according to groups of movement disorders. Results: The most prevalent movement disorders described in MS include restless leg syndrome, tremor, ataxia, parkinsonism, paroxysmal dyskinesias, chorea and ballism, facial myokymia, including hemifacial spasm and spastic paretic hemifacial contracture, tics, and tourettism. The anatomical basis of some of these disorders is poorly understood; however, the link between them and MS is supported by clinical and neuroimaging evidence. Treatment options are disorder-specific and often multidisciplinary, including pharmacological, surgical, and physical therapies. Discussion: Movements disorders in MS involve multiple pathophysiological processes and anatomical pathways. Since these disorders can be the presenting symptoms, they may aid in early diagnosis and managing the patient, including monitoring disease progression. Treatment of these disorders is a challenge. Further work needs to be done to understand the prevalence and the pathophysiological mechanisms responsible for movement disorders in MS.
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Jung IH, Chang KW, Park SH, Chang WS, Jung HH, Chang JW. Complications After Deep Brain Stimulation: A 21-Year Experience in 426 Patients. Front Aging Neurosci 2022; 14:819730. [PMID: 35462695 PMCID: PMC9022472 DOI: 10.3389/fnagi.2022.819730] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDeep brain stimulation is an established treatment for movement disorders such as Parkinson’s disease, essential tremor, and dystonia. However, various complications that occur after deep brain stimulation are a major concern for patients and neurosurgeons.ObjectiveThis study aimed to analyze various complications that occur after deep brain stimulation.MethodsWe reviewed the medical records of patients with a movement disorder who underwent bilateral deep brain stimulation between 2000 and 2020. Among them, patients requiring revision surgery were analyzed.ResultsA total of 426 patients underwent bilateral deep brain stimulation for a movement disorder. The primary disease was Parkinson’s disease in 315 patients, followed by dystonia in 71 patients and essential tremor in 40 patients. Twenty-six (6.1%) patients had complications requiring revision surgery; the most common complication was infection (12 patients, 2.8%).ConclusionVarious complications may occur after deep brain stimulation, and patient prognosis should be improved by reducing complications.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, South Korea
| | - Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - So Hee Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Jin Woo Chang,
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40
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Fox MD, Deuschl G. Converging on a neuromodulation target for tremor. Ann Neurol 2022; 91:581-584. [PMID: 35362142 DOI: 10.1002/ana.26361] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Michael D Fox
- Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gunther Deuschl
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Kiel, Germany
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Shetty N. Essential Tremor-Do We Have Better Therapeutics? A Review of Recent Advances and Future Directions. Curr Neurol Neurosci Rep 2022; 22:197-208. [PMID: 35235170 DOI: 10.1007/s11910-022-01185-8] [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] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Essential tremor (ET) is a very common condition that significantly impacts quality of life. Current medical treatments are quite limited, and while surgical treatments like deep brain stimulation (DBS) can be very effective, they come with their own limitations as well as procedural risks. This article reviews updates on recent advances and future directions in the treatment of ET. RECENT FINDINGS A new generation of pharmacologic agents specifically designed for ET is in clinical trials. Advances in DBS technology continue to improve this therapy. MRI-guided focused ultrasound (MRgFUS) is now an approved noninvasive ablative treatment for ET that is effective and shows potential for continuing improvement. The first peripheral stimulation device for ET has also now been approved. This article reviews updates on the treatment of ET, encompassing pharmacologic agents in clinical trials, DBS, MRgFUS, and noninvasive stimulation therapies. Recent treatment advances and future directions of development show a great deal of promise for ET therapeutics.
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Affiliation(s)
- Neil Shetty
- Parkinson's Disease and Movement Disorders Center, Department of Neurology, Northwestern University Feinberg School of Medicine, Abbott Hall, 11th Floor, 710 N. Lake Shore Drive, Chicago, IL, 60611, USA.
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Klostermann F, Ehlen F, Tiedt HO. Effects of thalamic and basal ganglia deep brain stimulation on language-related functions - Conceptual and clinical considerations. Eur J Paediatr Neurol 2022; 37:75-81. [PMID: 35149269 DOI: 10.1016/j.ejpn.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Abstract
Deep Brain Stimulation (DBS) is a therapy for various neurological movement disorders. It acts predominantly on motor symptoms, but may unfold a number of mostly subtle cognitive effects. In this regard, reports on particular language-related DBS sequels are comparably frequent, but difficult to overlook, given the heterogeneity of targeted structures in the brain, treated diseases, assessment methods and results reported. Accordingly, available knowledge was organized with respect to important aspects, such as the main DBS loci and surgical versus neuromodulatory therapy actions. Current views of biolinguistic underpinnings of the reviewed data, their clinical relevance and potential implications are discussed.
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Affiliation(s)
- Fabian Klostermann
- Charité - University Medicine Berlin, Clinic for Neurology, Campus Benjamin Franklin, Germany; Berlin School of Mind and Brain, Germany.
| | - Felicitas Ehlen
- Jewish Hospital Berlin, Clinic for Psychiatry and Psychotherapy, Germany
| | - Hannes Ole Tiedt
- Charité - University Medicine Berlin, Clinic for Neurology, Campus Benjamin Franklin, Germany
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Kvernmo N, Konglund AE, Reich MM, Roothans J, Pripp AH, Dietrichs E, Volkmann J, Skogseid IM. Deep brain stimulation for arm tremor: A randomized trial comparing two targets. Ann Neurol 2022; 91:585-601. [PMID: 35148020 PMCID: PMC9311445 DOI: 10.1002/ana.26317] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/14/2022] [Accepted: 02/07/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM) effectively suppresses arm tremor. Uncontrolled studies suggest the posterior subthalamic area (PSA) may be superior. We compared the intra-individual efficacy of VIM- versus PSA-DBS on tremor suppression and arm function. METHODS We performed a randomized, double-blind, crossover trial at Oslo University Hospital in patients (18-80 years) with isolated or combined action tremor affecting at least one arm. Four-contact DBS leads were implanted (bi- or unilaterally) with a trajectory to cover the VIM (upper two contacts) and PSA (lower two contacts). Patients were randomized (1:1 ratio) post-surgery to: Group 1, VIM-stimulation months 0-3 (period 1), then PSA-stimulation months 4-6 (period 2); Group 2, PSA-stimulation first, then VIM-stimulation. Primary endpoint was the difference in improvement from baseline to the end of the VIM- versus PSA-period in the sum of the dominant arm tremor scores of the Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS), items 5/6 + 10-14. RESULTS Forty-five patients were randomized to Group 1 (n = 23) or 2 (n = 22). In the primary endpoint per-protocol analysis (mixed model, n = 40), mean difference in the sum FTMTRS score improvement for the dominant arm was -2.65 points (95% CI -4.33 to -0.97; p = 0.002). The difference in favour of PSA stimulation was highly significant in period 2, but not period 1. INTERPRETATION Our randomized trial demonstrated that PSA stimulation provided superior tremor suppression compared with VIM stimulation. A period effect reducing tremor for up to three months in both groups was most likely attributed to a post-surgery stun effect. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Nadja Kvernmo
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Norway
| | - Ane E Konglund
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Martin M Reich
- Department of Neurology, University Hospital of Wuerzburg, Wuerzburg, Germany.,Visual DBS lab, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Jonas Roothans
- Visual DBS lab, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Are H Pripp
- Department of Biostatistics, Oslo University Hospital, Oslo, Norway
| | - Espen Dietrichs
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Norway
| | - Jens Volkmann
- Department of Neurology, University Hospital of Wuerzburg, Wuerzburg, Germany.,Institute of Clinical Medicine, University of Wuerzburg, Germany
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Pan MK, Kuo SH. Essential tremor: Clinical perspectives and pathophysiology. J Neurol Sci 2022; 435:120198. [PMID: 35299120 PMCID: PMC10363990 DOI: 10.1016/j.jns.2022.120198] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/01/2021] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
Essential tremor (ET) is one of the most common neurological disorders and can be highly disabling. In recent years, studies on the clinical perspectives and pathophysiology have advanced our understanding of ET. Specifically, clinical heterogeneity of ET, with co-existence of tremor and other neurological features such as dystonia, ataxia, and cognitive dysfunction, has been identified. The cerebellum has been found to be the key brain region for tremor generation, and structural alterations of the cerebellum have been extensively studied in ET. Finally, four main ET pathophysiologies have been proposed: 1) environmental exposures to β-carboline alkaloids and the consequent olivocerebellar hyper-excitation, 2) cerebellar GABA deficiency, 3) climbing fiber synaptic pathology with related cerebellar oscillatory activity, 4) extra-cerebellar oscillatory activity. While these four theories are not mutually exclusive, they can represent distinctive ET subtypes, indicating multiple types of abnormal brain circuitry can lead to action tremor. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.
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Binder DK, Shah BB, Elias WJ. Focused ultrasound and other lesioning in the treatment of tremor. J Neurol Sci 2022; 435:120193. [DOI: 10.1016/j.jns.2022.120193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/24/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
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Utility of routine surface electrophysiology to screen for functional tremor prior to surgical treatment of essential tremor. Clin Park Relat Disord 2022; 7:100149. [PMID: 35928768 PMCID: PMC9344345 DOI: 10.1016/j.prdoa.2022.100149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/26/2022] [Accepted: 06/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background Patients with functional tremor may be clinically misdiagnosed as “medication-refractory” essential tremor (ET) and referred for surgical treatment. Electrophysiology can screen for functional tremor and avoid inappropriate surgery. Objective To report the utility of surface electrophysiology (SEMG) to screen for functional tremor in patients referred for ET surgery. Methods Retrospective review of consecutive ET patients referred to the Mayo Clinic DBS clinic over 1.5 years. Included subjects had a clinical diagnosis of medication-refractory ET and completed presurgical workup including routine SEMG tremor study. Results Of 87 subjects, 9 (10%) were clinically suspected of functional tremor by the DBS neurologist. Electrophysiology confirmed functional tremor features in 7/9 and ET in the other 2/9; and newly identified 5 additional cases of functional tremor. There were 12 total confirmed cases of functional tremor: isolated in 1, and mixed functional tremor and ET in 11. Of 11 mixed patients, 6 with mild functional overlay were approved for surgery. The remaining 5 patients with moderate-severe functional overlay and the single patient with isolated functional tremor were referred to the functional tremor motor retraining program. Of these, 1 patient with mixed tremor had residual disabling organic ET after program completion and was later approved for surgery. Thus, 5/87 patients (6%) avoided unnecessary surgery. Conclusions Functional tremor may frequently overlay “medication-refractory” ET amongst patients referred for surgery, affecting 1 of 7 patients in our quaternary referral DBS center. Electrophysiology studies are useful to routinely screen patients and prevent unnecessary surgery.
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47
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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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Abstract
Essential tremor (ET) is one of the most common movement disorders, with a reported >60 million affected individuals worldwide. The definition and underlying pathophysiology of ET are contentious. Patients present primarily with motor features such as postural and action tremors, but may also have other non-motor features, including cognitive impairment and neuropsychiatric symptoms. Genetics account for most of the ET risk but environmental factors may also be involved. However, the variable penetrance and challenges in validating data make gene-environment analysis difficult. Structural changes in cerebellar Purkinje cells and neighbouring neuronal populations have been observed in post-mortem studies, and other studies have found GABAergic dysfunction and dysregulation of the cerebellar-thalamic-cortical circuitry. Commonly prescribed medications include propranolol and primidone. Deep brain stimulation and ultrasound thalamotomy are surgical options in patients with medically intractable ET. Further research in post-mortem studies, and animal and cell-based models may help identify new pathophysiological clues and therapeutic targets and, together with advances in omics and machine learning, may facilitate the development of precision medicine for patients with ET.
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Waschk A, Parpaley Y, Kruger J. A Multi-Modular System for the Visualization and Classification of MER Data During Neurostimulation Procedures. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:6281-6284. [PMID: 34892549 DOI: 10.1109/embc46164.2021.9631088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This paper proposes an interactive analysis and visualization tool for the accuracy improvement of electrode placement during neurostimulation therapy surgery. During the procedure, the presented system assists the surgeon in the crucial tissue type detection by providing a fused visualization of the current electrode location and the microelectrode recordings (MER). The system processes the MER in real-time and utilizes a convolutional neural network (CNN) to classify the targeted tissue type. In addition to presenting the MER in its raw waveform, the system also offers the visualization of the frequency domain and the result of the neural network. To further assist the decision-making process, additional visualization methods are integrated into the system. Using the pre-operative taken CT and MRI scans, the system offers 3D visualization in the form of direct volume rendering (DVR) and axis-aligned slice views in 2D. Both domains are enriched by the MER readings and the result of the machine learning classifier.
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50
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Stieglitz LH, Oertel MF, Accolla EA, Bally J, Bauer R, Baumann CR, Benninger D, Bohlhalter S, Büchele F, Hägele-Link S, Kägi G, Krack P, Krüger MT, Mahendran S, Möller JC, Mylius V, Piroth T, Werner B, Kaelin-Lang A. Consensus Statement on High-Intensity Focused Ultrasound for Functional Neurosurgery in Switzerland. Front Neurol 2021; 12:722762. [PMID: 34630296 PMCID: PMC8493868 DOI: 10.3389/fneur.2021.722762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) has evolved into a viable ablative treatment option for functional neurosurgery. However, it is not clear yet, how this new technology should be integrated into current and established clinical practice and a consensus should be found about recommended indications, stereotactic targets, patient selection, and outcome measurements. Objective: To sum up and unify current knowledge and clinical experience of Swiss neurological and neurosurgical communities regarding MRgHiFUS interventions for brain disorders to be published as a national consensus paper. Methods: Eighteen experienced neurosurgeons and neurologists practicing in Switzerland in the field of movement disorders and one health physicist representing 15 departments of 12 Swiss clinical centers and 5 medical societies participated in the workshop and contributed to the consensus paper. All experts have experience with current treatment modalities or with MRgHiFUS. They were invited to participate in two workshops and consensus meetings and one online meeting. As part of workshop preparations, a thorough literature review was undertaken and distributed among participants together with a list of relevant discussion topics. Special emphasis was put on current experience and practice, and areas of controversy regarding clinical application of MRgHiFUS for functional neurosurgery. Results: The recommendations addressed lesioning for treatment of brain disorders in general, and with respect to MRgHiFUS indications, stereotactic targets, treatment alternatives, patient selection and management, standardization of reporting and follow-up, and initialization of a national registry for interventional therapies of movement disorders. Good clinical evidence is presently only available for unilateral thalamic lesioning in treating essential tremor or tremor-dominant Parkinson's disease and, to a minor extent, for unilateral subthalamotomy for Parkinson's disease motor features. However, the workgroup unequivocally recommends further exploration and adaptation of MRgHiFUS-based functional lesioning interventions and confirms the need for outcome-based evaluation of these approaches based on a unified registry. MRgHiFUS and DBS should be evaluated by experts familiar with both methods, as they are mutually complementing therapy options to be appreciated for their distinct advantages and potential. Conclusion: This multidisciplinary consensus paper is a representative current recommendation for safe implementation and standardized practice of MRgHiFUS treatments for functional neurosurgery in Switzerland.
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Affiliation(s)
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Ettore A Accolla
- Neurology Unit, Department of Internal Medicine, Hôpital Fribourgeois (HFR)-Cantonal Hospital Fribourg, University of Fribourg, Fribourg, Switzerland
| | - Julien Bally
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Neurology, Geneva University Hospital and University of Geneva, Geneva, Switzerland
| | - Roland Bauer
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | | | - David Benninger
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephan Bohlhalter
- Neurocenter, Lucerne Cantonal Hospital, University of Zurich, Zurich, Switzerland
| | - Fabian Büchele
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Hägele-Link
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Paul Krack
- Department of Neurology, Inselspital, University Bern, Bern, Switzerland
| | - Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Sujitha Mahendran
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - J Carsten Möller
- Parkinson Center, Center for Neurological Rehabilitation, Zihlschlacht, Switzerland
| | - Veit Mylius
- Department of Neurology, Center for Neurorehabilitation, Valens, Switzerland
| | - Tobias Piroth
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Beat Werner
- Center for Magnetic Resonance (MR) Research, University Children's Hospital Zurich, Zurich, Switzerland
| | - Alain Kaelin-Lang
- Department of Neurology, Inselspital, University Bern, Bern, Switzerland.,Neurocenter of Southern Switzerland Ente Ospedaliero Cantonale (EOC), Regional Hospital Lugano, Lugano, Switzerland.,Faculty of Biomedical Neurosciences, Università Della Svizzera Italiana, Lugano, Switzerland
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