title: Gamma Knife thalamotomy for tremor in the magnetic resonance imaging era.
abstract: OBJECTIVE
  The surgical management of disabling tremor has gained renewed vigor with the availability of deep brain stimulation. However, in the face of an aging population of patients with increasing surgical comorbidities, noninvasive approaches for tremor management are needed. The authors' purpose was to study the technique and results of stereotactic radiosurgery performed in the era of MRI targeting.
  
  
  METHODS
  The authors evaluated outcomes in 86 patients (mean age 71 years; number of procedures 88) who underwent a unilateral Gamma Knife thalamotomy (GKT) for tremor during a 15-year period that spanned the era of MRI-based target selection (1996-2011). Symptoms were related to essential tremor in 48 patients (19 age ≥ 80 years and 3 age ≥ 90 years), Parkinson disease in 27 patients (11 age ≥ 80 years [1 patient underwent bilateral procedures]), and multiple sclerosis in 11 patients (1 patient underwent bilateral procedures). A single 4-mm isocenter was used to deliver a maximum dose of 140 Gy to the posterior-inferior region of the nucleus ventralis intermedius. The Fahn-Tolosa-Marin clinical tremor rating scale was used to grade tremor, handwriting, and ability to drink. The median follow-up was 23 months.
  
  
  RESULTS
  The mean tremor score was 3.28 ± 0.79 before and 1.81 ± 1.15 after (p < 0.0001) GKT; the mean handwriting score was 2.78 ± 0.82 and 1.62 ± 1.04, respectively (p < 0.0001); and the mean drinking score was 3.14 ± 0.78 and 1.80 ± 1.15, respectively (p < 0.0001). After GKT, 57 patients (66%) showed improvement in all 3 scores, 11 patients (13%) in 2 scores, and 2 patients (2%) in just 1 score. In 16 patients (19%) there was a failure to improve in any score. Two patients developed a temporary contralateral hemiparesis, 1 patient noted dysphagia, and 1 sustained facial sensory loss.
  
  
  CONCLUSIONS
  Gamma Knife thalamotomy in the MRI era was a safe and effective noninvasive surgical strategy for medically refractory tremor in the elderly or those with contraindications to deep brain stimulation or stereotactic radiofrequency (thermal) thalamotomy.
authors: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors: Ali
authors: A
authors: Kooshkabadi
authors: L Dade
authors: LD
authors: Lunsford
authors: Daniel
authors: D
authors: Tonetti
authors: John C
authors: JC
authors: Flickinger
authors: Douglas
authors: D
authors: Kondziolka
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000075202:Contraindications; D046690:Deep Brain Stimulation; D020329:Essential Tremor / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000150:complications; D010300:Parkinson Disease / Q000150:complications; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D013788:Thalamus / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome