title: Deep brain stimulation and frameless stereotactic radiosurgery in the treatment of bilateral parkinsonian tremor: target selection and case report of two patients.
abstract: Considerable positive experience in functional radiosurgery has been reported since Leksell's first experience in 1951, but the development of frameless radiosurgery was been limited because of the difficulty of identifying invisible functional targets. In this paper we report on two cases of bilateral parkinsonian tremor successfully treated with DBS on one side and with frameless radiosurgery on the contralateral side. We focus on the methodology developed to define the three-dimensional target coordinates for frameless radiosurgery. Two patients suffering from a disabling upper-limb parkinsonian tremor underwent frameless radiosurgical thalamotomy. To accurately identify the treatment target the CT gantry was treated as a stereotactic frame; a rototranslation between the origin of the screen and the origin of the stereotactic atlas allowed us to obtain atlas-registered 3D coordinates of each point on the CT axial brain slices. Both patients achieved complete bilateral tremor control by unilateral radiosurgery and contralateral DBS. We developed a method for determining the 3D coordinates of a known functional target to treat with frameless radiosurgery. Based on the initial experiences, frameless radiosurgery appears to be an alternative treatment for Parkinsonian upper limb tremor in the presence of increased surgical risks for DBS placement.
authors.affiliation: Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Via Celoria 11, 20133, Milan, Italy.
authors.forename: Angelo
authors.initials: A
authors.lastname: Franzini
authors.forename: Marcello
authors.initials: M
authors.lastname: Marchetti
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Brait
authors.forename: Ida
authors.initials: I
authors.lastname: Milanesi
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Messina
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Forapani
authors.forename: Giovanni
authors.initials: G
authors.lastname: Broggi
authors.forename: Laura
authors.initials: L
authors.lastname: Fariselli
mesh_terms: D000368:Aged; D046690:Deep Brain Stimulation / Q000379:methods* / Q000639:trends; D007839:Functional Laterality / Q000502:physiology; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods / Q000639:trends; D008297:Male; D038361:Neuronavigation / Q000379:methods* / Q000639:trends; D010300:Parkinson Disease / Q000628:therapy*; D014202:Tremor / Q000209:etiology / Q000628:therapy*