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Cesarano S, Saporito G, Sucapane P, Bruno F, Catalucci A, Pistoia ML, Splendiani A, Ricci A, Di Cesare E, Totaro R, Pistoia F. Staged magnetic resonance-guided focused ultrasound thalamotomy for the treatment of bilateral essential tremor and Parkinson's disease related tremor: a systematic review and critical appraisal of current knowledge. Front Neurol 2024; 15:1409727. [PMID: 38966080 PMCID: PMC11223629 DOI: 10.3389/fneur.2024.1409727] [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: 03/30/2024] [Accepted: 06/12/2024] [Indexed: 07/06/2024] Open
Abstract
Introduction Essential tremor (ET) and Parkinson's Disease (PD) are debilitating neurodegenerative disorders characterized by tremor as a predominant symptom, significantly impacting patients' quality of life. Magnetic Resonance-guided Focused Ultrasound (MRgFUS) Thalamotomy is an innovative therapeutic option for the treatment of unilateral medically refractory tremor with fewer adverse effects compared to traditional surgical interventions. A recent CE approval allows appropriate patients to have their second side treated. Objective The objective of this systematic review was to analyze available current knowledge about the use of MRgFUS for the treatment of bilateral ET and PD related tremor, to identify the effectiveness and the risks associated with bilateral treatment. Methods Eligible studies were identified by searching published studies in PubMed and Scopus databases from May 2014 to January 2024 and by identifying ongoing studies registered on the clinicaltrials.gov website. Data were summarized by considering the following information topics: the number of patients involved, the selected lesion target, the assessment tool used to evaluate clinical changes, the observed improvement, the reported side effects, and the time interval between the two treatments. The study was registered in PROSPERO (ID: CRD42024513178). Results Nine studies were eligible for this review, 7 for ET and 2 for PD. The involved population included a variable number of patients, ranging from 1 to 11 subjects for ET and from 10 to 15 subjects for PD. The main lesional targets were the ventral intermediate nucleus of the thalamus, the pallidothalamic tract and the cerebellothalamic tract bilaterally. All studies investigated the tremor relief through the Clinical Rating Scale for Tremor (CRST) in patients with ET, and through the Unified Parkinson's Disease Rating Scale (UPDRS) in patients with PD. A variable degree of improvement was observed, with all patients expressing overall satisfaction with the bilateral treatment. Adverse events were mild and transient, primarily involving gait disturbances, dysarthria, and ataxia. A standardized protocol for administering the two consecutive treatments was not identifiable; typically, the timing of the second treatment was delayed by at least 6 months. Conclusion Available evidence supports the effectiveness and safety of staged bilateral MRgFUS treatments for ET and PD-related tremor.
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Affiliation(s)
- Simone Cesarano
- 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
| | | | - Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | | | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore Hospital, L’Aquila, Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Rocco Totaro
- Department of Neurology, San Salvatore Hospital, L’Aquila, Italy
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
- Department of Neurology, San Salvatore Hospital, L’Aquila, Italy
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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] [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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Natera-Villalba E, Ruiz-Yanzi MA, Gasca-Salas C, Matarazzo M, Martínez-Fernández R. MR-guided focused ultrasound in movement disorders and beyond: Lessons learned and new frontiers. Parkinsonism Relat Disord 2024; 122:106040. [PMID: 38378311 DOI: 10.1016/j.parkreldis.2024.106040] [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: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
The development of MR-guided focused ultrasound (MRgFUS) has provided a new therapeutic tool for neuropsychiatric disorders. In contrast to previously available neurosurgical techniques, MRgFUS allows precise impact on deep brain structures without the need for incision and yields an immediate effect. In its high-intensity modality (MRgHIFU), it produces accurate therapeutic thermoablation in previously selected brain targets. Importantly, the production of the lesion is progressive and highly controlled in real-time by both neuroimaging and clinical means. MRgHIFU ablation is already an accepted and widely used treatment for medically-refractory Parkinson's disease and essential tremor. Notably, other neurological disorders and diverse brain targets, including bilateral treatments, are currently under examination. Conversely, the low-intensity modality (MRgLIFU) shows promising prospects in neuromodulation and transient blood-brain barrier opening (BBBO). In the former circumstance, MRgLIFU could serve as a powerful clinical and research tool for non-invasively modulating brain activity and function. BBBO, on the other hand, emerges as a potentially impactful method to influence disease pathogenesis and progression by increasing brain target engagement of putative therapeutic agents. While promising, these applications remain experimental. As a recently developed technology, MRgFUS is not without challenges and questions to be addressed. Further developments and broader experience are necessary to enhance MRgFUS capabilities in both research and clinical practice, as well as to define device constraints. This clinical mini-review aims to provide an overview of the main evidence of MRgFUS application and to highlight unmet needs and future potentialities of the technique.
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Affiliation(s)
- Elena Natera-Villalba
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; PhD Medicine Program, Universidad Autónoma de Madrid, Madrid, Spain
| | - María-Agustina Ruiz-Yanzi
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain
| | - Carmen Gasca-Salas
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain; University CEU-San Pablo, Madrid, Spain
| | - Michele Matarazzo
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain
| | - Raúl Martínez-Fernández
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain; University CEU-San Pablo, Madrid, Spain.
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Verhagen Metman L, Monje MHG, Obeso JA, Martínez-Fernández R. Focused ultrasound therapy: Back to the future. Parkinsonism Relat Disord 2024; 121:106023. [PMID: 38320923 DOI: 10.1016/j.parkreldis.2024.106023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/08/2024]
Affiliation(s)
- Leo Verhagen Metman
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Mariana H G Monje
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - José A Obeso
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain
| | - Raúl Martínez-Fernández
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain
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Visani E, Panzica F, Franceschetti S, Golfrè Andreasi N, Cilia R, Rinaldo S, Rossi Sebastiano D, Lanteri P, Eleopra R. Early cortico-muscular coherence and cortical network changes in Parkinson's patients treated with MRgFUS. Front Neurol 2024; 15:1362712. [PMID: 38585361 PMCID: PMC10995240 DOI: 10.3389/fneur.2024.1362712] [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: 12/28/2023] [Accepted: 02/26/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction To investigate cortical network changes using Magnetoencephalography (MEG) signals in Parkinson's disease (PD) patients undergoing Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy. Methods We evaluated the MEG signals in 16 PD patients with drug-refractory tremor before and after 12-month from MRgFUS unilateral lesion of the ventralis intermediate nucleus (Vim) of the thalamus contralateral to the most affected body side. We recorded patients 24 h before (T0) and 24 h after MRgFUS (T1). We analyzed signal epochs recorded at rest and during the isometric extension of the hand contralateral to thalamotomy. We evaluated cortico-muscular coherence (CMC), the out-strength index from non-primary motor areas to the pre-central area and connectivity indexes, using generalized partial directed coherence. Statistical analysis was performed using RMANOVA and post hoct-tests. Results Most changes found at T1 compared to T0 occurred in the beta band and included: (1) a re-adjustment of CMC distribution; (2) a reduced out-strength from non-primary motor areas toward the precentral area; (3) strongly reduced clustering coefficient values. These differences mainly occurred during motor activation and with few statistically significant changes at rest. Correlation analysis showed significant relationships between changes of out-strength and clustering coefficient in non-primary motor areas and the changes in clinical scores. Discussion One day after MRgFUS thalamotomy, PD patients showed a topographically reordered CMC and decreased cortico-cortical flow, together with a reduced local connection between different nodes. These findings suggest that the reordered cortico-muscular and cortical-networks in the beta band may represent an early physiological readjustment related to MRgFUS Vim lesion.
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Affiliation(s)
- Elisa Visani
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ferruccio Panzica
- Clinical Engineering, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvana Franceschetti
- Neurophysiopathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nico Golfrè Andreasi
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Cilia
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Rinaldo
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Paola Lanteri
- Neurophysiopathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Buzaev IV, Galimova RM, Nabiullina DI, Illarioshkin SN, Zagidullin NS, Safin SM. Magnetic resonance imaging-guided focused ultrasound thalamotomy launch with remote telemedicine international proctorship. Chronic Dis Transl Med 2024; 10:40-50. [PMID: 38450308 PMCID: PMC10914008 DOI: 10.1002/cdt3.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/12/2023] [Accepted: 08/08/2023] [Indexed: 03/08/2024] Open
Abstract
Background COVID-19 limitations have hindered the implementation of new technologies by preventing proctors from coming to the site. We share our first experience of magnetic resonance imaging (MRI)-guided focused ultrasound (MRgFUS) treatment with an international remote online proctorship, and develop and evaluate the methodology of remote MRgFUS proctorship. Methods This single-center, nonrandomized controlled prospective study included 94 patients: 27 with essential tremor (ET) and 67 with tremor-dominant Parkinson's disease (PD). The coming of proctors was impossible, so we arranged for the remote participation of proctors from the United Kingdom, Spain, and Israel. A total of 38 patients (40.4%) received telemedicine-proctored treatment (proctor group) and 56 received their treatment independently (solo group). We used the Clinical Rating Scale for Tremor (CRST) for ET patients and the Unified Parkinson's Disease Rating Scale (UPDRS) Part III for PD patients. Results In patients with ET, success rates were 81.8% (proctor group) and 100% (solo group) (p = 0.22). CRST reduction on the treated side was 71.43% [65.83%; 80.56%] (proctor group) versus 60.87% [53.99; 79.58] (solo group) (p = 0.19). None of the patients showed worsening of tremors within 1 year. In patients with PD, the success rates were 92.6% (proctor group) and 100% (solo group) (p = 0.08). The UPDRS Part III improvement was 30.1% (proctor group) versus 39.9% (solo group) (p = 0.003). The 1-year recurrence rate was 40% (proctor group) and 17.5% (solo group) (p = 0.04). No complications were observed at 6 months. Conclusions We developed a feasible and safe methodology for telemedicine remote online-proctored MRgFUS treatment. No significant difference was observed between the solo and developed remote proctor protocols in terms of complication rate, effect, and long-term results; however, UPDRS Part III improvement was better in the PD solo group. This study demonstrated that the MRgFUS international proctorship can be performed successfully remotely.
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Affiliation(s)
- Igor V. Buzaev
- Department of SurgeryBashkir State Medical UniversityUfaRussia
| | | | - Dinara I. Nabiullina
- Intelligent Neurosurgery Clinic, Ltd.International Medical Center V.S. Buzaev memorialUfaRussia
| | | | | | - Shamil M. Safin
- Department of SurgeryBashkir State Medical UniversityUfaRussia
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Momin SMB, Aquilina K, Bulstrode H, Taira T, Kalia S, Natalwala A. MRI-Guided Focused Ultrasound for the Treatment of Dystonia: A Narrative Review. Cureus 2024; 16:e54284. [PMID: 38500932 PMCID: PMC10945285 DOI: 10.7759/cureus.54284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Contemporary surgical management of dystonia includes neuromodulation via deep brain stimulation (DBS) or ablative techniques such as radiofrequency (RF) ablation. MRI-guided focused ultrasound (MRgFUS) is an emerging modality that uses high-intensity ultrasound to precisely ablate targets in the brain; this is incisionless, potentially avoiding the surgical risks of a burr hole and transcortical tract to reach the anatomical target. There is some evidence of efficacy in essential tremor and Parkinson's disease (PD), but, to date, there is no study aggregating the evidence of MRgFUS in dystonia. In this narrative review, we searched Medline, Embase, CINAHL, EBSCO, and ClinicalTrials.gov for primary studies and clinical trials on MRgFUS in the treatment of dystonia. Data were analyzed concerning dystonia phenotype, reported outcomes, and complications. PD-related dystonia was also included within the scope of the review. Using our search criteria, six articles on the use of MRgFUS in adult dystonia and three articles on the use of FUS in dystonia in PD were included. Four trials on the use of FUS in dystonia were also found on ClinicalTrials.gov, one of which was completed in December 2013. All included studies showed evidence of symptomatic improvement, mostly in focal hand dystonia; improvements were also found in dystonia-associated tremor, cervicobrachial dystonia, and dystonia-associated chronic neuropathic pain as well as PD-related dystonia. Reported complications included transient neurological deficits and persistent arm pain in one study. However, the evidence is limited to level-4 case series at present. MRgFUS is an emerging modality that appears to be safe and effective, particularly in focal hand dystonia, without major adverse effects. However, the quality of evidence is low at present, and long-term outcomes are unknown. High-quality prospective studies comparing MRgFUS to other surgical techniques will be useful in determining its role in the management of dystonia.
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Affiliation(s)
- Sheikh Muktadir Bin Momin
- Institute of Inflammation & Ageing, University of Birmingham, Birmingham, GBR
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, GBR
| | - Kristian Aquilina
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital, London, GBR
| | - Harry Bulstrode
- Department of Neurosurgery, Wellcome-MRC Cambridge Stem Cell Institute, Addenbrooke's Hospital, Cambridge, GBR
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, JPN
| | - Suneil Kalia
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, CAN
| | - Ammar Natalwala
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, GBR
- Department of Neuromuscular Diseases, Institute of Neurology, University College London, London, GBR
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Tian X, Hu R, He P, Ye J. Efficacy and safety of magnetic resonance-guided focused ultrasound for Parkinson's disease: a systematic review and meta-analysis. Front Neurol 2023; 14:1301240. [PMID: 38146437 PMCID: PMC10749343 DOI: 10.3389/fneur.2023.1301240] [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: 09/24/2023] [Accepted: 11/24/2023] [Indexed: 12/27/2023] Open
Abstract
Objective Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is a novel noninvasive treatment for drug-resistant Parkinson's disease (PD) related tremor. This study aims to evaluate MRgFUS's efficacy and safety in PD through a systematic review and meta-analysis, examining pre-and post-treatment MDS-UPDRSIII and/or CRST scores and associated adverse events. Materials and methods We conducted an extensive literature search across PubMed, Embase, Web of Science, and Cochrane Library databases, screening studies based on set criteria and analyzing MDS-UPDRSIII, CRST, and adverse events pre- and post-MRgFUS treatment. Results Out of 468 retrieved articles, 20 studies involving 258 patients, spanning 2014-2023, were included.17 studies indicated significant MDS-UPDRSIII score reductions post-MRgFUS treatment, while 3 showed significant CRST score declines. In the "on" medication state, pooled MDS-UPDRSIII scores at 1, 3, 6, and 12 months were 12.18 (95% CI: 5.83-18.52), 12.10 (95% CI: 8.22-15.97), 14.85 (95% CI: 9.28-20.41), and 20.65 (95% CI: 12.15-29.14) respectively. In the "off" state, scores were 11.45 (95% CI: -3.50-26.40), 14.71 (95% CI: 4.95-24.46), 21.52 (95% CI: 19.28-23.75), and 22.28 (95% CI: 15.26-29.30). Adverse events were typically mild and transient, with speech disturbances, ataxia, and sensory abnormalities being common post-operative neurological complications. Conclusion MRgFUS offers an effective and relatively safe treatment option for patients with drug-resistant PD-related tremor. Systematic review registration https://www.crd.york.ac.uk/prospero/, No. CRD42023428332.
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Affiliation(s)
- Xiaona Tian
- Eighth Clinical School, Guangzhou University of Chinese Medicine, Foshan, China
| | - Rongrui Hu
- Eighth Clinical School, Guangzhou University of Chinese Medicine, Foshan, China
| | - Peicong He
- Eighth Clinical School, Guangzhou University of Chinese Medicine, Foshan, China
| | - Jianhong Ye
- Endocrinology Department, Foshan Hospital of Traditional Chinese Medicine, Foshan, China
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Schechtmann G, Glud AN, Jourdain VA, Bergholt B, Sørensen JCH. "Suboptimal" placement of STN DBS electrodes as a novel strategy in Parkinson's disease? Acta Neurochir (Wien) 2023; 165:3943-3945. [PMID: 37792049 DOI: 10.1007/s00701-023-05796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Gastón Schechtmann
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.
| | - Andreas Nørgaard Glud
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | | | - Bo Bergholt
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Christian Hedemann Sørensen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Jamora RDG, Khu KJO, Sy MCC, Pascual JSG, Legaspi GD, Aguilar JA. Transcranial magnetic resonance-guided focused ultrasound pallidothalamic tractotomy for patients with X-linked dystonia-parkinsonism: a study protocol. BMC Neurol 2023; 23:306. [PMID: 37596524 PMCID: PMC10436542 DOI: 10.1186/s12883-023-03344-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 07/25/2023] [Indexed: 08/20/2023] Open
Abstract
Transcranial magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive method for controlling tremor and has recently been used in patients with X-linked dystonia-parkinsonism (XDP). This study aims to determine the improvement in dystonia and parkinsonism in patients with XDP after MRgFUS pallidothalamic tractotomy. This prospective study will be conducted at the Philippine General Hospital, University of the Philippines Manila. The primary outcome measure is the change in the pre- and post-treatment XDP-Movement Disorder Society of the Philippines Scale scores. In addition, demographic and clinical data will be collected, including the Burke-Fahn-Marsden Dystonia Rating Scale, Part III of the Movement Disorder Society-Unified Parkinson's disease Rating Scale score, XDP clinical and functional stage, the five-level EuroQol five-dimensional questionnaire, Montreal Cognitive Assessment scores, MRgFUS treatment parameters, and adverse events. Patients will be assessed within 24 hours of treatment, then at 2 weeks, 3 months, 6 months, 9 months, and 12 months post-treatment. This protocol was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2022-0271-01). Data collection began in January 2023. This protocol has been registered with ClinicalTrials.gov: Trial Registration number: NCT05592028.
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Affiliation(s)
- Roland Dominic G Jamora
- Division of Adult Neurology, Department of Neurosciences, College of Medicine, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Kathleen Joy O Khu
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Marie Charmaine C Sy
- Division of Adult Neurology, Department of Neurosciences, College of Medicine, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Juan Silvestre G Pascual
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Jose A Aguilar
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Dahmani L, Bai Y, Li M, Ren J, Shen L, Ma J, Li H, Wei W, Li P, Wang D, Du L, Cui W, Liu H, Wang M. Focused ultrasound thalamotomy for tremor treatment impacts the cerebello-thalamo-cortical network. NPJ Parkinsons Dis 2023; 9:90. [PMID: 37322044 DOI: 10.1038/s41531-023-00543-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023] Open
Abstract
High-intensity Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is a recent, non-invasive line of treatment for medication-resistant tremor. We used MRgFUS to produce small lesions in the thalamic ventral intermediate nucleus (VIM), an important node in the cerebello-thalamo-cortical tremor network, in 13 patients with tremor-dominant Parkinson's disease or essential tremor. Significant tremor alleviation in the target hand ensued (t(12) = 7.21, p < 0.001, two-tailed), which was strongly associated with the functional reorganization of the brain's hand region with the cerebellum (r = 0.91, p < 0.001, one-tailed). This reorganization potentially reflected a process of normalization, as there was a trend of increase in similarity between the hand cerebellar connectivity of the patients and that of a matched, healthy control group (n = 48) after treatment. Control regions in the ventral attention, dorsal attention, default, and frontoparietal networks, in comparison, exhibited no association with tremor alleviation and no normalization. More broadly, changes in functional connectivity were observed in regions belonging to the motor, limbic, visual, and dorsal attention networks, largely overlapping with regions connected to the lesion targets. Our results indicate that MRgFUS is a highly efficient treatment for tremor, and that lesioning the VIM may result in the reorganization of the cerebello-thalamo-cortical tremor network.
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Affiliation(s)
- Louisa Dahmani
- Department of Medical Imaging, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Yan Bai
- Department of Medical Imaging, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China
| | - Meiling Li
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Jianxun Ren
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Lunhao Shen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Jianjun Ma
- Department of Neurology, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiyang Li
- Department of Neurosurgery, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Wei
- Department of Medical Imaging, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengyu Li
- Department of Medical Imaging, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China
| | - Danhong Wang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Lei Du
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | | | - Hesheng Liu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA.
- Changping Laboratory, Beijing, China.
- Biomedical Pioneering Innovation Center, Peking University, Beijing, China.
| | - Meiyun Wang
- Department of Medical Imaging, Henan Provincial People's Hospital & People Hospital of Zhengzhou University, Zhengzhou, China.
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12
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Ko TH, Lee YH, Chan L, Tsai KWK, Hong CT, Lo WL. Magnetic Resonance-Guided focused ultrasound surgery for Parkinson's disease: A mini-review and comparison between deep brain stimulation. Parkinsonism Relat Disord 2023:105431. [PMID: 37164870 DOI: 10.1016/j.parkreldis.2023.105431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) is a new surgical treatment for Parkinson's disease (PD). Previous experience with radiofrequency lesionectomy and deep brain stimulation (DBS) has identified several candidate targets for MRgFUS intended to alleviate the motor symptoms of PD. The main advantage of MRgFUS is that it is incisionless. MRgFUS has certain limitations and is associated with adverse effects. The present study reviews the literature on conventional surgical interventions for PD, discusses recent studies on MRgFUS, and the comparison between DBS and MRgFUS for PD. The reviews aims to provide an essential reference for neurologists to select the appropriate treatments for patients with PD.
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Affiliation(s)
- Tzu-Hsiang Ko
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Yu-Hsuan Lee
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Lung Chan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | | | - Chien-Tai Hong
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
| | - Wei-Lun Lo
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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13
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Lu H, Wang X, Lou X. Current applications for magnetic resonance-guided focused ultrasound in the treatment of Parkinson's disease. Chin Med J (Engl) 2023; 136:780-787. [PMID: 36914938 PMCID: PMC10150909 DOI: 10.1097/cm9.0000000000002319] [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: 12/22/2022] [Indexed: 03/16/2023] Open
Abstract
ABSTRACT Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel and minimally invasive technology. Since the US Food and Drug Administration approved unilateral ventral intermediate nucleus-MRgFUS for medication-refractory essential tremor in 2016, studies on new indications, such as Parkinson's disease (PD), psychiatric diseases, and brain tumors, have been on the rise, and MRgFUS has become a promising method to treat such neurological diseases. Currently, as the second most common degenerative disease, PD is a research hotspot in the field of MRgFUS. The actions of MRgFUS on the brain range from thermoablation, blood-brain barrier (BBB) opening, to neuromodulation. Intensity is a key determinant of ultrasound actions. Generally, high intensity can be used to precisely thermoablate brain targets, whereas low intensity can be used as molecular therapies to modulate neuronal activity and open the BBB in conjunction with injected microbubbles. Here, we aimed to summarize advances in the application of MRgFUS for the treatment of PD, with a focus on thermal ablation, BBB opening, and neuromodulation, in the hope of informing clinicians of current applications.
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Affiliation(s)
- Haoxuan Lu
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing 100853, China
| | - Xiaoyu Wang
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing 100853, China
- School of Medicine, Nankai University, Tianjin 300071, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing 100853, China
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14
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Chen JC, Lu MK, Chen CM, Tsai CH. Stepwise Dual-Target Magnetic Resonance-Guided Focused Ultrasound in Tremor-Dominant Parkinson Disease: A Feasibility Study. World Neurosurg 2023; 171:e464-e470. [PMID: 36563853 DOI: 10.1016/j.wneu.2022.12.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) has been applied successfully in treating refractory tremors in Parkinson disease (PD). It generates a precise thermal ablation in a specific nucleus or tract, such as ventral intermediate nucleus (VIM) or pallidothalamic tract (PTT). Despite a single lesion improving parts of the PD symptoms, the feasibility and efficacy of a stepwise dual-lesion in VIM and PTT are yet to be explored. METHODS Three patients with tremor-dominant PD (aged 60.7 ± 6.0 years) received dual-target MRgFUS treatment with a series of primary and secondary outcome measures. The VIM and PTT were navigated based on individual magnetic resonance imaging planning of the brain. The primary outcome measures were the off-status Clinical Rating Scale for Tremor and Unified Parkinson's Disease Rating Scale part III (UPDRS-III). The secondary outcome measures included UPDRS I, II, IV, Hohen and Yahr score, Neuropsychiatry Inventory, Quality of life in PD Rating Scale, Non-Motor Symptoms Scale, and Clinical Global Impression. The baseline data were compared with those acquired 1 day and 1 month following the treatment. RESULTS The severity of tremor and motor deficits represented by Clinical Rating Scale for Tremor-part B and UPDRS III were significantly improved (P < 0.05 by nonparametric Mann-Whitney U tests) after dual-target ablations. The nonmotor symptoms investigated by UPDRS II and Non-Motor Symptoms Scale also showed significant improvement at the 1-day and 1-month follow-up. There was no adverse effect except temporary procedure-related headache and dizziness during the treatment. CONCLUSIONS Stepwise dual-lesion targeting VIM and PTT is a safe and effective MRgFUS therapeutic strategy for patients with PD.
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Affiliation(s)
- Jui-Cheng Chen
- Neuroscience and Brain Disease Center, China Medical University, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Neurology, China Medical University Hsinchu Hospital, Zhubei City, Taiwan; Neuroscience Laboratory, Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Kuei Lu
- Neuroscience and Brain Disease Center, China Medical University, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan; Neuroscience Laboratory, Department of Neurology, China Medical University Hospital, Taichung, Taiwan; Division of Parkinson's Disease and Movement Disorders, Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Chun-Ming Chen
- Neuroscience and Brain Disease Center, China Medical University, Taichung, Taiwan; Department of Radiology, China Medical University Hospital, Taichung, Taiwan
| | - Chon-Haw Tsai
- Neuroscience and Brain Disease Center, China Medical University, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Neuroscience Laboratory, Department of Neurology, China Medical University Hospital, Taichung, Taiwan; Division of Parkinson's Disease and Movement Disorders, Department of Neurology, China Medical University Hospital, Taichung, Taiwan.
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15
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Zhong YX, Liao JC, Liu X, Tian H, Deng LR, Long L. Low intensity focused ultrasound: a new prospect for the treatment of Parkinson's disease. Ann Med 2023; 55:2251145. [PMID: 37634059 PMCID: PMC10461511 DOI: 10.1080/07853890.2023.2251145] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/17/2023] [Accepted: 08/20/2023] [Indexed: 08/28/2023] Open
Abstract
Background: As a chronic and progressive neurodegenerative disease, Parkinson's disease (PD) still lacks effective and safe targeted drug therapy. Low-intensity focused ultrasound (LIFU), a new method to stimulate the brain and open the blood-brain barrier (BBB), has been widely concerned by PD researchers due to its non-invasive characteristics.Methods: PubMed was searched for the past 10 years using the terms 'focused ultrasound', 'transcranial ultrasound', 'pulse ultrasound', and 'Parkinson's disease'. Relevant citations were selected from the authors' references. After excluding articles describing high-intensity focused ultrasound or non-Parkinson's disease applications, we found more than 100 full-text analyses for pooled analysis.Results: Current preclinical studies have shown that LIFU could improve PD motor symptoms by regulating microglia activation, increasing neurotrophic factors, reducing oxidative stress, and promoting nerve repair and regeneration, while LIFU combined with microbubbles (MBs) can promote drugs to cross the BBB, which may become a new direction of PD treatment. Therefore, finding an efficient drug carrier system is the top priority of applying LIFU with MBs to deliver drugs.Conclusions: This article aims to review neuro-modulatory effect of LIFU and the possible biophysical mechanism in the treatment of PD, summarize the latest progress in delivering vehicles with MBs, and discuss its advantages and limitations.
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Affiliation(s)
- Yun-Xiao Zhong
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jin-Chi Liao
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xv Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hao Tian
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-Ren Deng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ling Long
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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16
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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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17
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Abusrair AH, Elsekaily W, Bohlega S. Tremor in Parkinson's Disease: From Pathophysiology to Advanced Therapies. Tremor Other Hyperkinet Mov (N Y) 2022; 12:29. [PMID: 36211804 PMCID: PMC9504742 DOI: 10.5334/tohm.712] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
Background Tremor is one of the most prevalent symptoms in Parkinson's Disease (PD). The progression and management of tremor in PD can be challenging, as response to dopaminergic agents might be relatively poor, particularly in patients with tremor-dominant PD compared to the akinetic/rigid subtype. In this review, we aim to highlight recent advances in the underlying pathogenesis and treatment modalities for tremor in PD. Methods A structured literature search through Embase was conducted using the terms "Parkinson's Disease" AND "tremor" OR "etiology" OR "management" OR "drug resistance" OR "therapy" OR "rehabilitation" OR "surgery." After initial screening, eligible articles were selected with a focus on published literature in the last 10 years. Discussion The underlying pathophysiology of tremor in PD remains complex and incompletely understood. Neurodegeneration of dopaminergic neurons in the retrorubral area, in addition to high-power neural oscillations in the cerebello-thalamo-cortical circuit and the basal ganglia, play a major role. Levodopa is the first-line therapeutic option for all motor symptoms, including tremor. The addition of dopamine agonists or anticholinergics can lead to further tremor reduction. Botulinum toxin injection is an effective alternative for patients with pharmacological-resistant tremor who are not seeking advanced therapies. Deep brain stimulation is the most well-established advanced therapy owing to its long-term efficacy, reversibility, and effectiveness in other motor symptoms and fluctuations. Magnetic resonance-guided focused ultrasound is a promising modality, which has the advantage of being incisionless. Cortical and peripheral electrical stimulation are non-invasive innovatory techniques that have demonstrated good efficacy in suppressing intractable tremor.
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Affiliation(s)
- Ali H. Abusrair
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Neurology, Department of Internal Medicine, Qatif Health Network, Qatif, Saudi Arabia
| | - Walaa Elsekaily
- College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Saeed Bohlega
- Movement Disorders Program, Neurosciences Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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18
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Update in the clinical application of focused ultrasound. Curr Opin Neurol 2022; 35:525-535. [PMID: 35788096 DOI: 10.1097/wco.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the most recent evidence about the clinical applicability of transcranial MRI-guided focused ultrasound (MRgFUS), including clinical evidence and indications, recent technical developments for its use and future prospects. RECENT FINDINGS Unilateral MRgFUS thalamotomy for both essential and parkinsonian tremors is an approved and well established therapy. Recent studies have focused on its long-term safety and efficacy as well as technical advances for refining the approach. Moreover, ultrasound has expanded its application in Parkinson's disease, with clinical trials successfully targeting other brain regions like the subthalamic nucleus, the globus pallidus and the pallidothalamic tract, providing benefits for features that thalamotomy neglects. New indications, such as focal dystonia or neuropsychiatric conditions (namely obsessive-compulsive disorder and depression) have also been explored, with encouraging preliminary results. Finally, the application of ultrasound in low-intensity modality allows other approaches like focal blood-brain barrier opening and neuromodulation, which promise to be highly relevant in translational research. SUMMARY MRgFUS is a growing emergent technique. Its application in clinical routine is becoming widely accepted as a therapeutic option. Novel approaches and new potential applications are anticipated.
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19
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Horisawa S, Kohara K, Nonaka T, Fukui A, Mochizuki T, Iijima M, Kawamata T, Taira T. Unilateral pallidothalamic tractotomy at Forel's field H1 for cervical dystonia. Ann Clin Transl Neurol 2022; 9:478-487. [PMID: 35261204 PMCID: PMC8994978 DOI: 10.1002/acn3.51532] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/12/2022] Open
Abstract
Background Neurosurgical ablation of Forel's field H1 for cervical dystonia, which is currently abandoned, was formerly used in the 1960s–1970s. Regardless of the lack of neuroimaging modalities and objective evaluation scales, the reported efficacy was significant. Although recent studies have reappraised the ablation of the pallidothalamic tract at Forel's field H1 for Parkinson's disease, the efficacy for cervical dystonia has not been investigated well. Methods Data of 35 patients with cervical dystonia who underwent unilateral pallidothalamic tractotomy at Forel's field H1 were retrospectively analyzed. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores, the neck score of the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), and adverse events were evaluated preoperatively and at the last available follow‐up period. Results The mean clinical follow‐up period was 13.9 ± 6.5 months. The mean TWSTRS total scores were 34.3 ± 14.0 preoperatively and 18.4 ± 16.5 at the last available follow‐up period (46.4% improvement, p < 0.0001). The BFMDRS neck score also improved significantly from 6.2 ± 2.9 preoperatively to 2.8 ± 2.8 at the last available follow‐up period (55.0% improvement on the neck score, p < 0.0001). Reduced hand dexterity in seven patients, hypophonia in five patients, dysarthria in four patients, and executive dysfunction in one patient were confirmed as adverse events at the last available follow‐up evaluation. One patient had postoperative hemorrhage. Conclusion The current study confirmed significant improvement in TWSTRS total scores and BFMDRS neck scores at the 13.9‐month follow‐up after unilateral pallidothalamic tractotomy. The pallidothalamic tract in Forel's field H1 is expected to be an alternative treatment target for cervical dystonia.
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Affiliation(s)
- Shiro Horisawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Kotaro Kohara
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Taku Nonaka
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsushi Fukui
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Mutsumi Iijima
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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20
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Stanziano M, Golfrè Andreasi N, Messina G, Rinaldo S, Palermo S, Verri M, Demichelis G, Medina JP, Ghielmetti F, Bonvegna S, Nigri A, Frazzetta G, D'Incerti L, Tringali G, DiMeco F, Eleopra R, Bruzzone MG. Resting State Functional Connectivity Signatures of MRgFUS Vim Thalamotomy in Parkinson's Disease: A Preliminary Study. Front Neurol 2022; 12:786734. [PMID: 35095731 PMCID: PMC8791196 DOI: 10.3389/fneur.2021.786734] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/02/2021] [Indexed: 12/03/2022] Open
Abstract
Magnetic Resonance-guided high-intensity Focused Ultrasound (MRgFUS) of the thalamic ventral intermediate nucleus (Vim) for tremor has increasingly gained interest as a new non-invasive alternative to standard neurosurgery. Resting state functional connectivity (rs-FC) correlates of MRgFUS have not been extensively investigated yet. A region of interest (ROI)-to-ROI rs-FC MRI “connectomic” analysis focusing on brain regions relevant for tremor was conducted on 15 tremor-dominant patients with Parkinson's disease who underwent MRgFUS. We tested whether rs-FC between tremor-related areas was modulated by MRgFUS at 1 and 3 months post-operatively, and whether such changes correlated with individual clinical outcomes assessed by the MDS-UPDRS-III sub items for tremor. Significant increase in FC was detected within bilateral primary motor (M1) cortices, as well as between bilateral M1 and crossed primary somatosensory cortices, and also between pallidum and the dentate nucleus of the untreated hemisphere. Correlation between disease duration and FC increase at 3 months was found between the putamen of both cerebral hemispheres and the Lobe VI of both cerebellar hemispheres, as well as between the Lobe VI of untreated cerebellar hemisphere with bilateral supplementary motor area (SMA). Drop-points value of MDS-UPDRS at 3 months correlated with post-treatment decrease in FC, between the anterior cingulate cortex and bilateral SMA, as well as between the Lobe VI of treated cerebellar hemisphere and the interpositus nucleus of untreated cerebellum. Tremor improvement at 3 months, expressed as percentage of intra-subject MDS-UPDRS changes, correlated with FC decrease between bilateral occipital fusiform gyrus and crossed Lobe VI and Vermis VI. Good responders (≥50% of baseline tremor improvement) showed reduced FC between bilateral SMA, between the interpositus nucleus of untreated cerebellum and the Lobe VI of treated cerebellum, as well as between the untreated SMA and the contralateral putamen. Good responders were characterized at baseline by crossed hypoconnectivity between bilateral putamen and M1, as well as between the putamen of the treated hemisphere and the contralateral SMA. We conclude that MRgFUS can effectively modulate brain FC within the tremor network. Such changes are associated with clinical outcome. The shifting mode of integration among the constituents of this network is, therefore, susceptible to external redirection despite the chronic nature of PD.
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Affiliation(s)
- Mario Stanziano
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy.,Neurosciences Department "Rita Levi Montalcini, " University of Turin, Turin, Italy
| | - Nico Golfrè Andreasi
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Messina
- Functional Neurosurgery Unit, Neurosurgery Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Rinaldo
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Palermo
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy.,European Innovation Partnership on Active and Healthy Ageing, Brussels, Belgium
| | - Mattia Verri
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Greta Demichelis
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jean Paul Medina
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Ghielmetti
- Health Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Salvatore Bonvegna
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Anna Nigri
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Ludovico D'Incerti
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Tringali
- Functional Neurosurgery Unit, Neurosurgery Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco DiMeco
- Neurosurgery Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy.,Pathophysiology and Transplantation Department, University of Milan, Milan, Italy.,Neurological Surgery Department, Johns Hopkins Medical School, Baltimore, MD, United States
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit, Clinical Neurosciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Neurologico Carlo Besta, Milan, Italy
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21
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Wang X, Xiong Y, Lin J, Lou X. Target Selection for Magnetic Resonance-Guided Focused Ultrasound in the Treatment of Parkinson's Disease. J Magn Reson Imaging 2022; 56:35-44. [PMID: 35081263 DOI: 10.1002/jmri.28080] [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] [Received: 12/20/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/03/2023] Open
Abstract
Parkinson's disease (PD) is a common, progressive, and incurable neurodegenerative disease. Pharmacological treatment is the first-line therapy for PD, including carbidopa-levodopa, dopamine agonists. However, some patients respond poorly to medication. For these patients, functional neurosurgical treatment is an important option. Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel, minimally invasive surgical option for patients refractory to drugs. Currently, several important anatomical structures can be targeted by MRgFUS in the treatment of PD. However, there is no uniform standard for target selection. This review summarizes the clinical studies on MRgFUS for PD, focusing on the relationship between different treatment targets and the relieved symptoms, to help clinicians determine the ideal therapeutic target for individual patients. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 4.
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Affiliation(s)
- Xiaoyu Wang
- Department of Radiology, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China.,School of Medicine, Nankai University, Tianjin, China
| | - Yongqin Xiong
- Department of Radiology, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Jiaji Lin
- Department of Radiology, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
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22
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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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23
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Focused ultrasound for functional neurosurgery. J Neurooncol 2021; 156:17-22. [PMID: 34383232 DOI: 10.1007/s11060-021-03818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Brain lesioning is a fundamental technique in the functional neurosurgery world. It has been investigated for decades and presented promising results long before novel pharmacological agents were introduced to treat movement disorders, psychiatric disorders, pain, and epilepsy. Ablative procedures were replaced by effective drugs during the 1950s and by Deep Brain Stimulation (DBS) in the 1990s as a reversible neuromodulation technique. In the last decade, however, the popularity of brain lesioning has increased again with the introduction of magnetic resonance-guided focused ultrasound (MRgFUS). OBJECTIVE In this review, we will cover the current and emerging role of MRgFUS in functional neurosurgery. METHODS Literature review from PubMed and compilation. RESULTS Investigated since 1930, MRgFUS is a technology enabling targeted energy delivery at the convergence of mechanical sound waves. Based on technological advancements in phased array ultrasound transducers, algorithms accounting for skull penetration by sound waves, and MR imaging for targeting and thermometry, MRgFUS is capable of brain lesioning with sub-millimeter precision and can be used in a variety of clinical indications. CONCLUSION MRgFUS is a promising technology evolving as a dominant tool in different functional neurosurgery procedures in movement disorders, psychiatric disorders, epilepsy, among others.
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24
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Ge Y, Wang Z, Gu F, Yang X, Chen Z, Dong W, Wang Z. Clinical application of magnetic resonance-guided focused ultrasound in Parkinson's disease: a meta-analysis of randomized clinical trials. Neurol Sci 2021; 42:3595-3604. [PMID: 34216307 DOI: 10.1007/s10072-021-05443-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND To evaluate the safety and efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) in the treatment of Parkinson's disease (PD). METHODS The databases of Medline, EMBASE, and the Cochrane Library were searched for eligible randomized controlled trials comparing focused ultrasound surgery (FUS) group vs. sham procedure group in PD. Weighted mean differences and standardized mean differences with corresponding 95% confidence intervals were used to summarize the primary outcome, namely, the effect of MRgFUS to improve limb tremor in PD patients and adverse events, and the secondary outcome, which is the effect of MRgFUS in improving the quality of life, activities of daily living, and non-motor symptoms. RESULTS The pooled analysis comprised 2 studies. The blinded phase lasted for 4 months in one experiment and up to 3 months in the other. The FUS group showed significant improvement in limb tremor on the treated side (SMD: - 1.20; 95% CI: - 2.06, - 0.34) and the ability to perform daily activities (SMD: - 0.86; 95% CI: - 1.41, - 0.32) compared to the sham group, but there were no significant group differences in other indicators. Of the process-related adverse events, dizziness (OR: 4.68; 95% CI: 1.20, 18.23) was more common in the treatment group, with no group differences in the remaining adverse events. CONCLUSIONS These findings suggest beneficial effects of MRgFUS in PD patients with no serious side effects. Larger multicenter studies are needed in the future to select the most appropriate target and surgical device setup parameters.
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Affiliation(s)
- Yi Ge
- Department of Neurology, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Zilan Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Feng Gu
- First Clinical Medical School, Soochow University, Suzhou, 215006, Jiangsu Province, China
| | - Xingyu Yang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
| | - Wanli Dong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China.
- Department of Neurology, Dushuhu Public Hospital Affiliated To Soochow University, Jiangsu Province, Suzhou, 215006, China.
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Jiangsu Province, 188 Shizi Street, Suzhou, 215006, China
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25
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Transcranial Magnetic Resonance-Guided Focused Ultrasound in X-Linked Dystonia-Parkinsonism. Life (Basel) 2021; 11:life11050392. [PMID: 33925939 PMCID: PMC8145494 DOI: 10.3390/life11050392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022] Open
Abstract
X-linked dystonia-parkinsonism (XDP) is a neurodegenerative condition found among males with maternal ancestry from Panay Island, Philippines. The treatment options are limited. We report on our experience of three XDP patients who underwent transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) pallidothalamic tractotomy. The three patients were all genetically confirmed XDP, with a mean XDP-Movement Disorder Society of the Philippines (MDSP) Scale score of 68.7/200. All patients were on stable doses of their oral medications and their last botulinum toxin injection was 12 months prior to study. Two patients complained of moderate to severe arm pain 2-7 months after the procedure. There was an overall improvement in the XDP-MDSP Scale score of 36.2% (18.7 vs. 15) at 6 months and 30.1% (68.7 vs. 45.5) at 1 year. Notably, there was worsening of the nonmotor subscale (part IIIB, nonbehavioral aspect) by 350% at 1 year. While these numbers are encouraging, there is a need to do a larger study on the safety and efficacy of tcMRgFUS on XDP.
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