title: Magnetic resonance-guided focused ultrasound thalamotomy for tremor: a report of 30 Parkinson's disease and essential tremor cases.
abstract: OBJECTIVE Thalamotomy of the ventral intermediate nucleus (VIM) is effective in alleviating medication-resistant tremor in patients with essential tremor (ET) and Parkinson's disease (PD). MR-guided focused ultrasound (MRgFUS) is an innovative technology that enables noninvasive thalamotomy via thermal ablation. METHODS Patients with severe medication-resistant tremor underwent unilateral VIM thalamotomy using MRgFUS. Effects on tremor were evaluated using the Clinical Rating Scale for Tremor (CRST) in patients with ET and by the motor part of the Unified Parkinson's Disease Rating Scale (UPDRS) in patients with PD and ET-PD (defined as patients with ET who developed PD many years later). Quality of life in ET was measured by the Quality of Life in Essential Tremor (QUEST) questionnaire and in PD by the PD Questionnaire (PDQ-39). RESULTS Thirty patients underwent MRgFUS, including 18 with ET, 9 with PD, and 3 with ET-PD. The mean age of the study population was 68.9 ± 8.3 years (range 46-87 years) with a mean disease duration of 12.1 ± 8.9 years (range 2-30 years). MRgFUS created a lesion at the planned target in all patients, resulting in cessation of tremor in the treated hand immediately following treatment. At 1 month posttreatment, the mean CRST score of the patients with ET decreased from 40.7 ± 11.6 to 9.3 ± 7.1 (p < 0.001) and was 8.2 ± 5.0 six months after treatment (p < 0.001, compared with baseline). Average QUEST scores decreased from 44.8 ± 12.9 to 13.1 ± 13.2 (p < 0.001) and was 12.3 ± 7.2 six months after treatment (p < 0.001). In patients with PD, the mean score of the motor part of the UPDRS decreased from 24.9 ± 8.0 to 16.4 ± 11.1 (p = 0.042) at 1 month and was 13.4 ± 9.2 six months after treatment (p = 0.009, compared with baseline). The mean PDQ-39 score decreased from 38.6 ± 16.8 to 26.1 ± 7.2 (p = 0.036) and was 20.6 ± 8.8 six months after treatment (p = 0.008). During follow-up of 6-24 months (mean 11.5 ± 7.2 months, median 12.0 months), tremor reappeared in 6 of the patients (2 with ET, 2 with PD, and 2 with ET-PD), to a lesser degree than before the procedure in 5. Adverse events that transiently occurred during sonication included headache (n = 11), short-lasting vertigo (n = 14) and dizziness (n = 4), nausea (n = 3), burning scalp sensation (n = 3), vomiting (n = 2) and lip paresthesia (n = 2). Adverse events that lasted after the procedure included gait ataxia (n = 5), unsteady feeling (n = 4), taste disturbances (n = 4), asthenia (n = 4), and hand ataxia (n = 3). No adverse event lasted beyond 3 months. Patients underwent on average 21.0 ± 6.9 sonications (range 14-45 sonications) with an average maximal sonication time of 16.0 ± 3.0 seconds (range 13-24 seconds). The mean maximal energy reached was 12,500 ± 4274 J (range 5850-23,040 J) with a mean maximal temperature of 56.5° ± 2.2°C (range 55°-60°C). CONCLUSIONS MRgFUS VIM thalamotomy to relieve medication-resistant tremor was safe and effective in patients with ET, PD, and ET-PD. Current results emphasize the superior adverse events profile of MRgFUS over other surgical approaches for treating tremor with similar efficacy. Large randomized studies are needed to assess prolonged efficacy and safety.
authors.affiliation: Departments of1Neurosurgery.|2Technion Faculty of Medicine, Haifa,Israel.
authors.forename: Menashe
authors.initials: M
authors.lastname: Zaaroor
authors.affiliation: Departments of1Neurosurgery.
authors.forename: Alon
authors.initials: A
authors.lastname: Sinai
authors.affiliation: 2Technion Faculty of Medicine, Haifa,Israel.|3Radiology, and.
authors.forename: Dorith
authors.initials: D
authors.lastname: Goldsher
authors.affiliation: 3Radiology, and.
authors.forename: Ayelet
authors.initials: A
authors.lastname: Eran
authors.affiliation: 4Neurology, Rambam Health Care Campus; and.
authors.forename: Maria
authors.initials: M
authors.lastname: Nassar
authors.affiliation: 2Technion Faculty of Medicine, Haifa,Israel.|4Neurology, Rambam Health Care Campus; and.
authors.forename: Ilana
authors.initials: I
authors.lastname: Schlesinger
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020329:Essential Tremor / Q000000981:diagnostic imaging* / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053783:Magnetic Resonance Imaging, Interventional; D008297:Male; D008875:Middle Aged; D010300:Parkinson Disease / Q000000981:diagnostic imaging* / Q000628:therapy*; D011788:Quality of Life; D012720:Severity of Illness Index; D013787:Thalamic Nuclei; D016896:Treatment Outcome; D014464:Ultrasonic Therapy / Q000009:adverse effects
keywords: AC-PC = anterior commissure-posterior commissure; CRST = Clinical Rating Scale for Tremor; DBS = deep brain stimulation; ET = essential tremor; MR-guided focused ultrasound; MRgFUS = MR-guided focused ultrasound; PD = Parkinson's disease; PDQ-39 = PD Questionnaire; Parkinson's disease; QUEST = Quality of Life in Essential Tremor; RF = radiofrequency; UPDRS = Unified Parkinson's Disease Rating Scale; VIM = ventral intermediate nucleus; essential tremor; functional neurosurgery; thalamotomy; treatment