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Bruno F, Badini P, Innocenzi A, Saporito G, Catalucci A, Sucapane P, Barile A, Cesare ED, Marini C, Pistoia F, Splendiani A. Early re-emerging tremor after MRgFUS thalamotomy: case-control analysis of procedural and imaging features. Front Neurol 2024; 15:1356613. [PMID: 38903176 PMCID: PMC11187326 DOI: 10.3389/fneur.2024.1356613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/15/2024] [Indexed: 06/22/2024] Open
Abstract
Purpose This study aimed to identify possible prognostic factors determining early tremor relapse after Magnetic Resonance guided Focused Ultrasound Surgery (MRgFUS) thalamotomy in patients with essential tremor (ET) and Parkinson's disease (PD). Methods Nine patients (six ET and three PD) who underwent Vim MRgFUS thalamotomy in a single institution and developed early re-emergent tremor were analyzed. A control group of patients matched pairwise for sex, pathology, age, disease duration, and skull density ratio (SDR) was selected to compare the technical-procedural data and MR imaging evidence. MR imaging findings compared between groups included lesion shape and volume in multiparametric sequences, as well as Fractiona Anisotropy (FA) and Apparent Diffusion Coefficient (ADC) values derived from Diffusion Tensor Imaging Diffusion Weighted Imaging (DTI) and Diffusion Weighted Imaging (DWI) sequences. Results We did not find statistically significant differences in gender and age between the two groups. Technical and procedural parameters were also similar in both treatment groups. In MRI analysis, we found lesions of similar size but with greater caudal extension in the control group with stable outcomes compared to patients with tremor relapse. Conclusion In our analysis of early recurrences after thalamotomy with focused ultrasound, there were neither technical and procedural differences nor prognostic factors related to lesion size or ablation temperatures. Greater caudal extension of the lesion in patients without recurrence might suggest the importance of spatial consolidation during treatment.
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Affiliation(s)
- Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, L’Aquila, Italy
| | - Pierfrancesco Badini
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Innocenzi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Gennaro Saporito
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alessia Catalucci
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, L’Aquila, Italy
| | | | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Neurology, San Salvatore Hospital, L’Aquila, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Neuroradiology and Interventional Radiology, San Salvatore Hospital, L’Aquila, Italy
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Hori H, Yamada Y, Nakano M, Ouchi T, Takasaki M, Iijima K, Taira T, Abe K, Iwamuro H. Improvement in Intraoperative Image Quality in Transcranial Magnetic Resonance-Guided Focused Ultrasound Surgery Using Transmitter Gain Adjustment. Stereotact Funct Neurosurg 2023; 101:223-231. [PMID: 37379811 PMCID: PMC10614472 DOI: 10.1159/000531009] [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: 02/24/2023] [Accepted: 04/24/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Transcranial magnetic resonance-guided focused ultrasound surgery (TcMRgFUS) has the advantage of allowing immediate evaluation of therapeutic effects after each sonication and intraoperative magnetic resonance imaging (MRI) to visualize the lesion. When the image shows that the lesion has missed the planned target and the therapeutic effects are insufficient, the target of the subsequent ablation can be finely adjusted based on the image. The precision of this adjustment is determined by the image quality. However, the current intraoperative image quality with a 3.0T MRI system is insufficient for precisely detecting the lesion. Thus, we developed and validated a method for improving intraoperative image quality. METHODS Because intraoperative image quality is affected by transmitter gain (TG), we acquired T2-weighted images (T2WIs) with two types of TG: the automatically adjusted TG (auto TG) and the manually adjusted TG (manual TG). To evaluate the character of images with 2 TGs, the actual flip angle (FA), the image uniformity, and the signal-to-noise ratio (SNR) were measured using a phantom. Then, to assess the quality of intraoperative images, T2WIs with both TGs were acquired during TcMRgFUS for 5 patients. The contrast-to-noise ratio (CNR) of the lesion was retrospectively estimated. RESULTS The images of the phantom with the auto TG showed substantial variations between the preset and actual FAs (p < 0.01), whereas on the images with the manual TG, there were no variations between the two FAs (p > 0.05). The total image uniformity was considerably lower with the manual TG than with the auto TG (p < 0.01), indicating that the image's signal values with the manual TG were more uniform. The manual TG produced significantly higher SNRs than the auto TG (p < 0.01). In the clinical study, the lesions were clearly detected in intraoperative images with the manual TG, but they were difficult to identify in images with the auto TG. The CNR of lesions in images with manual TG was considerably higher than in images with auto TG (p < 0.01). CONCLUSION Regarding intraoperative T2WIs using a 3.0T MRI system during TcMRgFUS, the manual TG method improved image quality and delineated the ablative lesion more clearly than the current method with auto TG.
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Affiliation(s)
- Hiroki Hori
- Department of FUS Center, Moriyama Neurosurgical Center Hospital, Tokyo, Japan
| | - Yusuke Yamada
- Department of Radiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - Masayuki Nakano
- Department of Neurosurgery, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | - Takahiro Ouchi
- Department of Neurology, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | - Masahito Takasaki
- Department of Anesthesiology, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | - Ken Iijima
- Department of Diagnostic Radiology, Saitama Sekishinkai Hospital, Saitama, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Keiichi Abe
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
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3
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Pae C, Kim MJ, Chang WS, Jung HH, Chang KW, Eo J, Park HJ, Chang JW. Differences in intrinsic functional networks in patients with essential tremor who had good and poor long-term responses after thalamotomy performed using MR-guided ultrasound. J Neurosurg 2023; 138:318-328. [PMID: 35901685 DOI: 10.3171/2022.5.jns22324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Thalamotomy at the nucleus ventralis intermedius using MR-guided focused ultrasound has been an effective treatment method for essential tremor (ET). However, this is not true for all cases, even for successful ablation. How the brain differs in patients with ET between those with long-term good and poor outcomes is not clear. To analyze the functional connectivity difference between patients in whom thalamotomy was effective and those in whom thalamotomy was ineffective and its prognostic role in ET treatment, the authors evaluated preoperative resting-state functional MRI in thalamotomy-treated patients. METHODS Preoperative resting-state functional MRI data in 85 patients with ET, who were experiencing tremor relief at the time of treatment and were followed up for a minimum of 6 months after the procedure, were collected for the study. The authors conducted a graph independent component analysis of the functional connectivity matrices of tremor-related networks. The patients were divided into thalamotomy-effective and thalamotomy-ineffective groups (thalamotomy-effective group, ≥ 50% motor symptom reduction; thalamotomy-ineffective group, < 50% motor symptom reduction at 6 months after treatment) and the authors compared network components between groups. RESULTS Seventy-two (84.7%) of the 85 patients showed ≥ 50% tremor reduction from baseline at 6 months after thalamotomy. The network analysis shows significant suppression of functional network components with connections between the areas of the cerebellum and the basal ganglia and thalamus, but enhancement of those between the premotor cortex and supplementary motor area in the noneffective group compared to the effective group. CONCLUSIONS The present study demonstrates that patients in the noneffective group have suppressed functional subnetworks in the cerebellum and subcortex regions and have enhanced functional subnetworks among motor-sensory cortical networks compared to the thalamotomy-effective group. Therefore, the authors suggest that the functional connectivity pattern might be a possible predictive factor for outcomes of MR-guided focused ultrasound thalamotomy.
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Affiliation(s)
- Chongwon Pae
- 1Center for Systems and Translational Brain Sciences, Institute of Human Complexity and Systems Science, Yonsei University, Seoul.,2Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul.,8Department of Psychiatry, Bundang CHA Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Myung Ji Kim
- 3Department of Neurosurgery, Korea University College of Medicine, Korea University Medical Center, Ansan Hospital, Gyeonggi-do
| | - Won Seok Chang
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul.,5Center for Innovative Functional Neurosurgery, Brain Research Institute, Seoul
| | - Hyun Ho Jung
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul.,5Center for Innovative Functional Neurosurgery, Brain Research Institute, Seoul
| | - Kyung Won Chang
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul
| | - Jinseok Eo
- 1Center for Systems and Translational Brain Sciences, Institute of Human Complexity and Systems Science, Yonsei University, Seoul.,2Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul.,6Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul
| | - Hae-Jeong Park
- 1Center for Systems and Translational Brain Sciences, Institute of Human Complexity and Systems Science, Yonsei University, Seoul.,2Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul.,6Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul.,7Department of Cognitive Science, Yonsei University, Seoul; and
| | - Jin Woo Chang
- 4Department of Neurosurgery, Yonsei University College of Medicine, Seoul.,5Center for Innovative Functional Neurosurgery, Brain Research Institute, Seoul
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Sammartino F, Yeh FC, Krishna V. Intraoperative lesion characterization after focused ultrasound thalamotomy. J Neurosurg 2022; 137:459-467. [PMID: 34972085 DOI: 10.3171/2021.10.jns211651] [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: 07/02/2021] [Accepted: 10/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Outcomes after focused ultrasound ablation (FUSA) for essential tremor remain heterogeneous, despite therapeutic promise. Clinical outcomes are directly related to the volume and location of the therapeutic lesions, consistent with CNS ablative therapies. Recent data demonstrate that postoperative diffusion MRI, specifically the quantification of intracellular diffusion by restricted diffusion imaging (RDI), can accurately characterize focused ultrasound lesions. However, it is unclear whether RDI can reliably detect focused ultrasound lesions intraoperatively (i.e., within a few minutes of lesioning) and whether the intraoperative lesions predict delayed clinical outcomes. METHODS An intraoperative imaging protocol was implemented that included RDI and T2-weighted imaging in addition to intraoperative MR thermography. Lesion characteristics were defined with each sequence and then compared. An imaging-outcomes analysis was performed to determine lesion characteristics associated with delayed clinical outcomes. RESULTS Intraoperative RDI accurately identified the volume and location of focused ultrasound lesions. Intraoperative T2-weighted imaging underestimated the lesion volume but accurately identified the location. Intraoperative RDI revealed that lesions of the ventral border of the ventral intermediate nucleus were significantly associated with postoperative tremor improvement. In contrast, the lesions extending into the inferolateral white matter were associated with postoperative ataxia. CONCLUSIONS These data support the acquisition of intraoperative RDI to characterize focused ultrasound lesions. Future research should test the histological correlates of intraoperative RDI and test whether it can be developed as feedback to optimize the current technique of FUSA.
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Affiliation(s)
| | - Fang-Cheng Yeh
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Vibhor Krishna
- 1Department of Neurosurgery, The Ohio State University, Columbus, Ohio; and
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5
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Yamamoto K, Lozano AM, Fasano A. Commentary: Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor in the Setting of Prior Craniotomy. Oper Neurosurg (Hagerstown) 2022; 22:e147-e149. [PMID: 35030144 DOI: 10.1227/ons.0000000000000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada.,Krembil Research Institute, Toronto, Canada
| | - Alfonso Fasano
- Krembil Research Institute, Toronto, Canada.,Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto, Toronto, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada
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6
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Titova NV, Katunina EA, Tairova RT, Sen'ko IV, Dzhafarov VM, Malykhina EA. [The problem of pharmacoresistant tremor in Parkinson's disease and essential tremor]. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:24-30. [PMID: 36279225 DOI: 10.17116/jnevro202212210124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
MR-guided focused ultrasound (MRg-FUS) is a new noninvasive method for the treatment of contralateral disabling and pharmacoresistant tremor. Clinical studies have confirmed the high efficacy and safety of using MRg-FUS in patients with essential tremor and Parkinson's disease, in short and long-term studies. Advantages of this method in comparison with currently used invasive and noninvasive technics, potential brain target areas, the possibility of bilateral intervention, indications and contraindications are discussed.
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Affiliation(s)
- N V Titova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E A Katunina
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - R T Tairova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Sen'ko
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - V M Dzhafarov
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - E A Malykhina
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
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7
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Morrison MA, Lee AT, Martin AJ, Dietiker C, Brown EG, Wang DD. DBS targeting for essential tremor using intersectional dentato-rubro-thalamic tractography and direct proton density visualization of the VIM: technical note on 2 cases. J Neurosurg 2021; 135:806-814. [PMID: 33450737 DOI: 10.3171/2020.8.jns201378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Direct visualization of the ventral intermediate nucleus (VIM) of the thalamus on standard MRI sequences remains elusive. Therefore, deep brain stimulation (DBS) surgery for essential tremor (ET) indirectly targets the VIM using atlas-derived consensus coordinates and requires awake intraoperative testing to confirm clinical benefits. The objective of this study was to evaluate the utility of proton density (PD)-weighted MRI and tractography of the intersecting dentato-rubro-thalamic tract (DRTT) for direct "intersectional" targeting of the VIM in ET. METHODS DBS targets were selected by identifying the VIM on PD-weighted images relative to the DRTT in 2 patients with ET. Tremor reduction was confirmed with intraoperative clinical testing. Intended target coordinates based on the direct intersectional targeting technique were compared with consensus coordinates obtained with indirect targeting. Pre- and postoperative tremor scores were assessed using the Fahn-Tolosa-Marin tremor rating scale (TRS). RESULTS Planned DBS coordinates based on direct versus indirect targeting of the VIM differed in both the anteroposterior (range 0 to 2.3) and lateral (range -0.7 to 1) directions. For 1 patient, indirect targeting-without PD-weighted visualization of the VIM and DRTT-would have likely resulted in suboptimal electrode placement within the VIM. At the 3-month follow-up, both patients demonstrated significant improvement in tremor symptoms subjectively and according to the TRS (case 1: 68%, case 2: 72%). CONCLUSIONS Direct intersectional targeting of the VIM using PD-weighted imaging and DRTT tractography is a feasible method for DBS placement in patients with ET. These advanced targeting techniques can supplement awake intraoperative testing or be used independently in asleep cases to improve surgical efficiency and confidence.
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Affiliation(s)
- Melanie A Morrison
- 2Department of Radiology & Biomedical Imaging, University of California, San Francisco; and
| | - Anthony T Lee
- 1Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco
| | - Alastair J Martin
- 2Department of Radiology & Biomedical Imaging, University of California, San Francisco; and
| | - Cameron Dietiker
- 3Department of Neurology, Movement Disorders and Neuromodulation Center, Weill Institute for Neurosciences, University of California, San Francisco, California
| | - Ethan G Brown
- 3Department of Neurology, Movement Disorders and Neuromodulation Center, Weill Institute for Neurosciences, University of California, San Francisco, California
| | - Doris D Wang
- 1Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco
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8
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Valentino F, Cosentino G, Maugeri R, Giammalva R, Iacopino GD, Marrale M, Bartolotta TV, Gagliardo C. Is Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound a Repeatable Treatment Option? Case Report of a Retreated Patient With Tremor Combined With Parkinsonism. Oper Neurosurg (Hagerstown) 2021; 18:577-582. [PMID: 31598711 DOI: 10.1093/ons/opz300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 07/29/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In recent years, transcranial Magnetic Resonance Imaging-guided Focused Ultrasound (tcMRgFUS) treatments for functional neurological disorders are giving a new thrust to the field of therapeutic brain lesioning. OBJECTIVE To present the case of a patient affected by tremor combined with Parkinsonism who underwent a second tcMRgFUS thalamotomy because of relapsing tremor after a few months from the first tcMRgFUS treatment. METHODS A 72-yr-old, right-handed man, came to our observation because of a disabling tremor affecting his upper limbs, refusing any invasive surgical procedure and already treated by tcMRgFUS left Vim thalamotomy. However, clinical benefit had brief duration, as a progressive recurrence of tremor on the right upper limb was observed after a few months from the first treatment. Thus, the patient underwent a new left-sided tcMRgFUS procedure 6 mo after the former treatment. RESULTS After the second procedure, an immediate and complete relief from tremor on the right upper limb was achieved with clinical benefit that persisted up to a 6-mo follow-up. CONCLUSION Since tcMRgFUS doesn't use ionizing radiations and it is incision-less, repeated and staged treatment procedures have always been hypothesized. Our report suggests that tcMRgFUS retreatment might actually be a feasible, safe, and effective option in selected patients in whom an optimal clinical outcome is not achieved after the first treatment session. However, future well-designed studies in large samples are needed to assess the possible risks of retreatment and the optimal timing of reintervention as well as eligibility and exclusion criteria.
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Affiliation(s)
- Francesca Valentino
- Neurology Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giuseppe Cosentino
- Neurology Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy.,Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy.,Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Italy, IRCCS Mondino Foundation, Pavia, Italy
| | - Rosario Maugeri
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy
| | - Roberto Giammalva
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy
| | - Gerardo Domenico Iacopino
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Paltermo, Italy
| | - Maurizio Marrale
- Department of Physics and Chemistry, University of Palermo, Palermo, Italy
| | - Tommaso Vincenzo Bartolotta
- Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Cesare Gagliardo
- Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, University of Palermo, Palermo, Italy
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9
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De Vloo P, Boutet A, Elias GJB, Gramer RM, Joel SE, Llinas M, Kucharczyk W, Fasano A, Hamani C, Lozano AM. Dysgeusia induced and resolved by focused ultrasound thalamotomy: case report. J Neurosurg 2021; 136:215-220. [PMID: 34144526 DOI: 10.3171/2020.11.jns202882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/13/2020] [Indexed: 11/06/2022]
Abstract
Dysgeusia, or distorted taste, has recently been acknowledged as a complication of thalamic ablation or thalamic deep brain stimulation as a treatment of tremor. In a unique patient, left-sided MR-guided focused ultrasound thalamotomy improved right-sided essential tremor but also induced severe dysgeusia. Although dysgeusia persisted and caused substantial weight loss, tremor slowly relapsed. Therefore, 19 months after the first procedure, the patient underwent a second focused ultrasound thalamotomy procedure, which again improved tremor but also completely resolved the dysgeusia. On the basis of normative and patient-specific whole-brain tractography, the authors determined the relationship between the thalamotomy lesions and the medial border of the medial lemniscus-a surrogate for the solitariothalamic gustatory fibers-after the first and second focused ultrasound thalamotomy procedures. Both tractography methods suggested partial and complete disruption of the solitariothalamic gustatory fibers after the first and second thalamotomy procedures, respectively. The tractography findings in this unique patient demonstrate that incomplete and complete disruption of a neural pathway can induce and resolve symptoms, respectively, and serve as the rationale for ablative procedures for neurological and psychiatric disorders.
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Affiliation(s)
- Philippe De Vloo
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,2Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Vlaams-Brabant, Belgium
| | - Alexandre Boutet
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,3Joint Department of Medical Imaging, and
| | - Gavin J B Elias
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
| | - Robert M Gramer
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
| | - Suresh E Joel
- 5General Electric Global Research Center, Bangalore, India
| | - Maheleth Llinas
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
| | | | - Alfonso Fasano
- 4Krembil Research Institute, Toronto, Ontario, Canada.,6Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, and Division of Neurology, University of Toronto, Ontario, Canada; and.,7Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Clement Hamani
- 8Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Andres M Lozano
- 1Division of Neurosurgery, Department of Surgery, Toronto Western Hospital-University Health Network.,4Krembil Research Institute, Toronto, Ontario, Canada
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10
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Hemi-parkinsonism and return of essential tremors after MRgFUS thalamotomy: Case report and review of procedural complications affecting ventral thalamic nuclei. eNeurologicalSci 2021; 23:100339. [PMID: 33937534 PMCID: PMC8076700 DOI: 10.1016/j.ensci.2021.100339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 11/22/2022] Open
Abstract
Magnetic resonance guided focused ultrasound (MRgFUS) thalamotomy targets the ventral intermediate nucleus of the thalamus and has been shown to be safe and effective to treat medication-resistant essential tremors. Improvement in tremor scores, posture and action scores, disability scores and quality of life scores have been reported in patients treated with this procedure. Adverse events are usually transient and non-severe. We present a patient who underwent MRgFUS thalamotomy of the left VIM and developed new-onset parkinsonian features predominantly on the right side and return of essential tremors a few years after the procedure. Changes in speech (hypophonia and dysarthria), gait imbalance and postural instability, bradykinesia, and cogwheeling rigidity occurred, likely due to involvement of the fiber tracts through the ventrolateral subnuclei and the adjacent ventral anterior thalamic nuclei and other surrounding structures. We describe side effects of MRgFUS thalamotomy in our patient compared to previous reports and review the thalamic nuclei and surrounding structures that can be affected during procedure, causing these effects.
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11
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Giammalva GR, Gagliardo C, Marrone S, Paolini F, Gerardi RM, Umana GE, Yağmurlu K, Chaurasia B, Scalia G, Midiri F, La Grutta L, Basile L, Gulì C, Messina D, Pino MA, Graziano F, Tumbiolo S, Iacopino DG, Maugeri R. Focused Ultrasound in Neuroscience. State of the Art and Future Perspectives. Brain Sci 2021; 11:84. [PMID: 33435152 PMCID: PMC7827488 DOI: 10.3390/brainsci11010084] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/14/2022] Open
Abstract
Transcranial MR-guided Focused ultrasound (tcMRgFUS) is a surgical procedure that adopts focused ultrasounds beam towards a specific therapeutic target through the intact skull. The convergence of focused ultrasound beams onto the target produces tissue effects through released energy. Regarding neurosurgical applications, tcMRgFUS has been successfully adopted as a non-invasive procedure for ablative purposes such as thalamotomy, pallidotomy, and subthalamotomy for movement disorders. Several studies confirmed the effectiveness of tcMRgFUS in the treatment of several neurological conditions, ranging from motor disorders to psychiatric disorders. Moreover, using low-frequencies tcMRgFUS systems temporarily disrupts the blood-brain barrier, making this procedure suitable in neuro-oncology and neurodegenerative disease for controlled drug delivery. Nowadays, tcMRgFUS represents one of the most promising and fascinating technologies in neuroscience. Since it is an emerging technology, tcMRgFUS is still the subject of countless disparate studies, even if its effectiveness has been already proven in many experimental and therapeutic fields. Therefore, although many studies have been carried out, many others are still needed to increase the degree of knowledge of the innumerable potentials of tcMRgFUS and thus expand the future fields of application of this technology.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Cesare Gagliardo
- Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (C.G.); (F.M.)
| | - Salvatore Marrone
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Federica Paolini
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Rosa Maria Gerardi
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | | | - Kaan Yağmurlu
- Departments of Neuroscience and Neurosurgery, University of Virginia Health System, Charlottesville, VA 22903, USA;
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj 44300, Nepal;
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance “Garibaldi”, 95122 Catania, Italy; (G.S.); (F.G.)
| | - Federico Midiri
- Section of Radiological Sciences, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (C.G.); (F.M.)
| | - Ludovico La Grutta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties-ProMISE, University of Palermo, 90127 Palermo, Italy;
| | - Luigi Basile
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Carlo Gulì
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Domenico Messina
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Maria Angela Pino
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Francesca Graziano
- Department of Neurosurgery, Highly Specialized Hospital of National Importance “Garibaldi”, 95122 Catania, Italy; (G.S.); (F.G.)
| | - Silvana Tumbiolo
- Division of Neurosurgery, Villa Sofia Hospital, 90146 Palermo, Italy;
| | - Domenico Gerardo Iacopino
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
| | - Rosario Maugeri
- Neurosurgery Unit, Department of Biomedicine, Neurosciences & Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (G.R.G.); (S.M.); (F.P.); (R.M.G.); (L.B.); (C.G.); (D.M.); (M.A.P.); (D.G.I.); (R.M.)
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12
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Meng Y, Hynynen K, Lipsman N. Applications of focused ultrasound in the brain: from thermoablation to drug delivery. Nat Rev Neurol 2020; 17:7-22. [PMID: 33106619 DOI: 10.1038/s41582-020-00418-z] [Citation(s) in RCA: 192] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
Focused ultrasound (FUS) is a disruptive medical technology, and its implementation in the clinic represents the culmination of decades of research. Lying at the convergence of physics, engineering, imaging, biology and neuroscience, FUS offers the ability to non-invasively and precisely intervene in key circuits that drive common and challenging brain conditions. The actions of FUS in the brain take many forms, ranging from transient blood-brain barrier opening and neuromodulation to permanent thermoablation. Over the past 5 years, we have seen a dramatic expansion of indications for and experience with FUS in humans, with a resultant exponential increase in academic and public interest in the technology. Applications now span the clinical spectrum in neurological and psychiatric diseases, with insights still emerging from preclinical models and human trials. In this Review, we provide a comprehensive overview of therapeutic ultrasound and its current and emerging indications in the brain. We examine the potential impact of FUS on the landscape of brain therapies as well as the challenges facing further advancement and broader adoption of this promising minimally invasive therapeutic alternative.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Harquail Centre for Neuromodulation, Toronto, ON, Canada.,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Biophysics and Institute of Biomaterials & Biomedical Engineering (IBBME), University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Harquail Centre for Neuromodulation, Toronto, ON, Canada. .,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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13
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Su JH, Choi EY, Tourdias T, Saranathan M, Halpern CH, Henderson JM, Pauly KB, Ghanouni P, Rutt BK. Improved Vim targeting for focused ultrasound ablation treatment of essential tremor: A probabilistic and patient-specific approach. Hum Brain Mapp 2020; 41:4769-4788. [PMID: 32762005 PMCID: PMC7643361 DOI: 10.1002/hbm.25157] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/12/2020] [Accepted: 07/10/2020] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) ablation of the ventral intermediate (Vim) thalamic nucleus is an incisionless treatment for essential tremor (ET). The standard initial targeting method uses an approximate, atlas-based stereotactic approach. We developed a new patient-specific targeting method to identify an individual's Vim and the optimal MRgFUS target region therein for suppression of tremor. In this retrospective study of 14 ET patients treated with MRgFUS, we investigated the ability of WMnMPRAGE, a highly sensitive and robust sequence for imaging gray matter-white matter contrast, to identify the Vim, FUS ablation, and a clinically efficacious region within the Vim in individual patients. We found that WMnMPRAGE can directly visualize the Vim in ET patients, segmenting this nucleus using manual or automated segmentation capabilities developed by our group. WMnMPRAGE also delineated the ablation's core and penumbra, and showed that all patients' ablation cores lay primarily within their Vim segmentations. We found no significant correlations between standard ablation features (e.g., ablation volume, Vim-ablation overlap) and 1-month post-treatment clinical outcome. We then defined a group-based probabilistic target, which was nonlinearly warped to individual brains; this target was located within the Vim for all patients. The overlaps between this target and patient ablation cores correlated significantly with 1-month clinical outcome (r = -.57, p = .03), in contrast to the standard target (r = -.23, p = .44). We conclude that WMnMPRAGE is a highly sensitive sequence for segmenting Vim and ablation boundaries in individual patients, allowing us to find a novel tremor-associated center within Vim and potentially improving MRgFUS treatment for ET.
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Affiliation(s)
- Jason H Su
- Department of Radiology, Stanford University, Stanford, California, USA.,Department of Electrical Engineering, Stanford University, Stanford, California, USA
| | - Eun Young Choi
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Thomas Tourdias
- Department of Neuroradiology, Bordeaux University Hospital, Bordeaux, France.,INSERM U1215, Neurocentre Magendie, University of Bordeaux, Bordeaux, France
| | | | - Casey H Halpern
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Jaimie M Henderson
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Kim Butts Pauly
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Pejman Ghanouni
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Brian K Rutt
- Department of Radiology, Stanford University, Stanford, California, USA
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14
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Saluja S, Barbosa DAN, Parker JJ, Huang Y, Jensen MR, Ngo V, Santini VE, Pauly KB, Ghanouni P, McNab JA, Halpern CH. Case Report on Deep Brain Stimulation Rescue After Suboptimal MR-Guided Focused Ultrasound Thalamotomy for Essential Tremor: A Tractography-Based Investigation. Front Hum Neurosci 2020; 14:191. [PMID: 32676015 PMCID: PMC7333679 DOI: 10.3389/fnhum.2020.00191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022] Open
Abstract
Essential tremor (ET) is the most prevalent movement disorder in adults, and can often be medically refractory, requiring surgical intervention. MRI-guided focused ultrasound (MRgFUS) is a less invasive procedure that uses ultrasonic waves to induce lesions in the ventralis intermedius nucleus (VIM) to treat refractory ET. As with all procedures for treating ET, optimal targeting during MRgFUS is essential for efficacy and durability. Various studies have reported cases of tremor recurrence following MRgFUS and long-term outcome data is limited to 3–4 years. We present a tractography-based investigation on a case of DBS rescue for medically refractory ET that was treated with MRgFUS that was interrupted due to the development of dysarthria during the procedure. After initial improvement, her hand tremor started to recur within 6 months after treatment, and bilateral DBS was performed targeting the VIM 24 months after MRgFUS. DBS induced long-term tremor control with monopolar stimulation. Diffusion MRI tractography was used to reconstruct the dentatorubrothalamic (DRTT) and corticothalmic (CTT) tracts being modulated by the procedures to understand the variability in efficacy between MRgFUS and DBS in treating ET in our patient. By comparing the MRgFUS lesion and DBS volume of activated tissue (VAT), we found that the MRgFUS lesion was located ventromedially to the VAT, and was less than 10% of the size of the VAT. While the lesion encompassed the same proportion of DRTT streamlines, it encompassed fewer CTT streamlines than the VAT. Our findings indicate the need for further investigation of targeting the CTT when using neuromodulatory procedures to treat refractory ET for more permanent tremor relief.
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Affiliation(s)
- Sabir Saluja
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael R Jensen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Vyvian Ngo
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Veronica E Santini
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Kim Butts Pauly
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Pejman Ghanouni
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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15
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MRI follow-up after magnetic resonance-guided focused ultrasound for non-invasive thalamotomy: the neuroradiologist's perspective. Neuroradiology 2020; 62:1111-1122. [PMID: 32363482 PMCID: PMC7410861 DOI: 10.1007/s00234-020-02433-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/07/2020] [Indexed: 11/29/2022]
Abstract
Purpose Magnetic resonance-guided focused ultrasound (MRgFUS) systems are increasingly used to non-invasively treat tremor; consensus on imaging follow-up is poor in these patients. This study aims to elucidate how MRgFUS lesions evolve for a radiological readership with regard to clinical outcome. Methods MRgFUS-induced lesions and oedema were retrospectively evaluated based on DWI, SWI, T2-weighted and T1-weighted 3-T MRI data acquired 30 min and 3, 30 and 180 days after MRgFUS (n = 9 essential tremor, n = 1 Parkinson’s patients). Lesions were assessed volumetrically, visually and by ADC measurements and compared with clinical effects using non-parametric testing. Results Thirty minutes after treatment, all lesions could be identified on T2-weighted images. Immediate oedema was rare (n = 1). Lesion volume as well as oedema reached a maximum on day 3 with a mean lesion size of 0.4 ± 0.2 cm3 and an oedema volume 3.7 ± 1.2 times the lesion volume. On day 3, a distinct diffusion-restricted rim was noted that corresponded well with SWI. Lesion shrinkage after day 3 was observed in all sequences. Lesions were no longer detectable on DWI in n = 7/10, on T2-weighted images in n = 4/10 and on T1-weighted images in n = 4/10 on day 180. No infarcts or haemorrhage were observed. There was no correlation between lesion size and initial motor skill improvement (p = 0.99). Tremor reduction dynamics correlated strongly with lesion shrinkage between days 3 and 180 (p = 0.01, R = 0.76). Conclusion In conclusion, cerebral MRgFUS lesions variably shrink over months. SWI is the sequence of choice to identify lesions after 6 months. Lesion volume is arguably associated with intermediate-term outcome.
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16
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Halpern CH, Santini V, Lipsman N, Lozano AM, Schwartz ML, Shah BB, Elias WJ, Cosgrove GR, Hayes MT, McDannold N, Aldrich C, Eisenberg HM, Gandhi D, Taira T, Gwinn R, Ro S, Witt J, Jung NY, Chang JW, Rosenberg J, Ghanouni P. Three-year follow-up of prospective trial of focused ultrasound thalamotomy for essential tremor. Neurology 2019; 93:e2284-e2293. [PMID: 31748250 DOI: 10.1212/wnl.0000000000008561] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/20/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) thalamotomy is effective, durable, and safe for patients with medication-refractory essential tremor (ET), we assessed clinical outcomes at 3-year follow-up of a controlled multicenter prospective trial. METHODS Outcomes were based on the Clinical Rating Scale for Tremor, including hand combined tremor-motor (scale of 0-32), functional disability (scale of 0-32), and postural tremor (scale of 0-4) scores, and total scores from the Quality of Life in Essential Tremor Questionnaire (scale of 0-100). Scores at 36 months were compared with baseline and at 6 months after treatment to assess for efficacy and durability. Adverse events were also reported. RESULTS Measured scores remained improved from baseline to 36 months (all p < 0.0001). Range of improvement from baseline was 38%-50% in hand tremor, 43%-56% in disability, 50%-75% in postural tremor, and 27%-42% in quality of life. When compared to scores at 6 months, median scores increased for hand tremor (95% confidence interval [CI] 0-2, p = 0.0098) and disability (95% CI 1-4, p = 0.0001). During the third follow-up year, all previously noted adverse events remained mild or moderate, none worsened, 2 resolved, and no new adverse events occurred. CONCLUSIONS Results at 3 years after unilateral tcMRgFUS thalamotomy for ET show continued benefit, and no progressive or delayed complications. Patients may experience mild degradation in some treatment metrics by 3 years, though improvement from baseline remains significant. CLINICALTRIALSGOV IDENTIFIER NCT01827904. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with severe ET, unilateral tcMRgFUS thalamotomy provides durable benefit after 3 years.
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Affiliation(s)
- Casey H Halpern
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea.
| | - Veronica Santini
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Nir Lipsman
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Andres M Lozano
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Michael L Schwartz
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Binit B Shah
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - W Jeff Elias
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Garth R Cosgrove
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Michael T Hayes
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Nathan McDannold
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Christina Aldrich
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Howard M Eisenberg
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Dheeraj Gandhi
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Takaomi Taira
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Ryder Gwinn
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Susie Ro
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Jennifer Witt
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Na Young Jung
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Jin Woo Chang
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Jarrett Rosenberg
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea
| | - Pejman Ghanouni
- From the Departments of Neurosurgery (C.H.H.), Neurology (V.S.), and Radiology (J.R., P.G.), Stanford University School of Medicine, CA; Department of Neurosurgery (N.L., A.M.L., M.L.S.), University of Toronto, Canada; Department of Neurology (B.B.S., W.J.E.), University of Virginia, Charlottesville; Departments of Neurosurgery (G.R.C.), Neurology (M.T.H.), and Radiology (N.M.), Brigham and Women's Hospital, Boston, MA; Departments of Neurosurgery (C.A., H.M.E.) and Radiology (D.G.), University of Maryland, Baltimore; Department of Neurosurgery (T.T.), Tokyo Women's Medical University, Japan; Departments of Neurosurgery (R.G.) and Neurology (S.R., J.W.), Swedish Hospital Seattle, WA; and Department of Neurosurgery (N.Y.J., J.W.C.), Yonsei University, Seoul, Republic of Korea.
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