Bilateral staged magnetic resonance-guided focused ultrasound thalamotomy for the treatment of essential tremor: a case series study

Martínez‐Fernández, Raúl; Mahendran, Sujitha; Pineda‐Pardo, José A.; Imbach, Lukas L.; Máñez-Miró, Jorge U; Büchele, Fabian; Álamo, Marta del; Rodríguez‐Rojas, Rafael; Hernández-Fernández, Frida; Werner, Beat; Matarazzo, Michele; Obeso, Ignacio; Gonzalez-Quarante, Lain Hermes; Deuschl, G.; Stieglitz, Lennart; Baumann, Christian R.; Obeso, José A.

doi:10.1136/jnnp-2020-325278

Cited by 43 publications

(33 citation statements)

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“…A recent retrospective series of 9 patients who underwent bilateral MRgFUS thalamotomies at 2 centers was recently published and suggested the intervention might be safe 29 . We report here the first prospective study of bilateral thalamotomies.…”

Section: Discussionmentioning

confidence: 86%

Bilateral Focused Ultrasound Thalamotomy for Essential Tremor (BEST‐FUS Phase 2 Trial)

et al. 2021

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A BS TRACT: Background: In patients with medically refractory essential tremor, unilateral magnetic resonanceguided focused ultrasound thalamotomy can improve contralateral tremor. However, this procedure does not address ipsilateral symptoms. Objective: The objective of the current study was to determine whether bilateral thalamotomies can be performed with an acceptable safety profile where benefits outweigh adverse effects. Methods: We conducted a prospective, single-arm, single-blinded phase 2 trial of second-side magnetic resonance-guided focused ultrasound thalamotomy in patients with essential tremor. Patients were followed for 3 months. The primary outcome was the change in quality of life relative to baseline, as well as the answer to the question "Given what you know now, would you treat the second side again?". Secondary outcomes included tremor, gait, speech, and adverse effects. Results: Ten patients were analyzed. The study met both primary outcomes, with the intervention resulting in clinically significant improvement in quality of life at 3 months (mean Quality of Life in Essential Tremor score difference, 19.7; 95%CI,; P = 0.004) and all patients reporting that they would elect to receive the secondside treatment again. Tremor significantly improved in all patients. Seven experienced mild adverse effects, including 2 with transient gait impairment and a fall, 1 with dysarthria and dysphagia, and 1 with mild dysphagia persisting at 3 months.

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Section: Discussionmentioning

confidence: 86%

Bilateral Focused Ultrasound Thalamotomy for Essential Tremor (BEST‐FUS Phase 2 Trial)

et al. 2021

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“…The recent publications by Martínez‐Fernández et al, 1 Iorio‐Morin et al, 2 and Fukutome et al 3 reported encouraging results after staged bilateral MRgHiFUS thalamotomy in essential tremor patients. These observations indicate that staged bilateral ablations with MRgHiFUS might be possible and safe.…”

Section: Discussionmentioning

confidence: 95%

Bilateral Focused Ultrasound Pallidotomy for Parkinson‐Related Facial Dyskinesia—A Case Report

Stieglitz

Mahendran

Oertel

et al. 2022

Movement Disord Clin Pract

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BackgroundBackground: For safety reasons, both magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) thalamotomy and pallidotomy are currently approved exclusively for unilateral treatment, but axial symptoms like levodopa-induced orofacial dyskinesia require a bilateral approach. Objectives Objectives: We report the first case of successful bilateral MRgHiFUS pallidotomy for peak-dose dyskinesia in a patient with Parkinson's disease (PD). Methods Methods: The treatment decision was based on the patient's reluctance toward brain implants and pump therapies and the fact that he had limited access to a deep brain stimulation center in his home country. The treatment was planned as staged procedure with an interval of 18 months because of travel restrictions because of the coronavirus disease (COVID)-19 pandemic. ResultsResults: After the second treatment, levodopa-induced orofacial dyskinesia remitted and improved bradykinesia and rigidity with stable gait and good postural reflexes. Conclusions Conclusions: This promising result suggests that in selected PD patients with dyskinesia, staged bilateral MRgHiFUS pallidotomy might be considered.Magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) is still a relatively new treatment option for movement disorders. The Food and Drug Administration (FDA) approved MRgHiFUS thalamotomy in July 2016 for the treatment of essential tremor, and in December 2018, an approval for treatment of tremor-dominant Parkinson's disease (PD) followed. Only very recently, in November 2021, the method gained an expansion of FDA approval to target the globus pallidus internus (GPi) to treat other PD symptoms including bradykinesia, rigidity, and dyskinesia. For safety reasons, both MRgHiFUS thalamotomy and pallidotomy are currently approved exclusively for unilateral treatment. We report the first case of a bilateral MRgHiFUS based pallidotomy for the treatment of disabling axial levodopa (L-dopa)-induced dyskinesia in a patient suffering from PD in the form of a named patient use. Methods Case DescriptionWe report the case of a 77-year-old Jordanian male patient. He was diagnosed with PD in 2018. After earlier onset of prodromal symptoms including hyposmia and rapid eye movement (REM) sleep behavior disorder, first motor symptoms including bradykinesia, and mild tremor started in 2016, together with mild depression and loss of weight because of reduced appetite. Immediately after diagnosis, treatment with L-dopa-carbidopa and amantadine was started, with satisfactory improvement of bradykinesia. However, in early 2020, disabling perioral peakdose dyskinesia occurred, leading to the introduction of amantadine that was later discontinued again because of loss of efficacy.

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“…However, majority of the available data for bilateral thalamotomy were published from the 1960s to 1980s when MRI and CT were not generally available to plan and confirm the ablative targets. Recent studies of bilateral thalamotomy indicated that dysarthria was mild or transient (19)(20)(21)(22)(23)(24). Nevertheless, the second thalamotomy should be carefully considered, and for a safe second thalamotomy, it is recommended to verify the absence of adverse events associated with the first thalamotomy, keep the longest possible interval between the first and second surgery (at least 12 moths), include patients aged less than 70 years, and ensure the smallest possible lesion volume.…”

Section: Discussionmentioning

confidence: 99%

Case Report: Long-Term Suppression of Paroxysmal Kinesigenic Dyskinesia After Bilateral Thalamotomy

et al. 2021

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Background: Paroxysmal kinesigenic dyskinesia (PKD) is a movement disorder characterized by transient dyskinetic movements, including dystonia, chorea, or both, triggered by sudden voluntary movements. Carbamazepine and other antiepileptic drugs (AEDs) are widely used in the treatment of PKD, and they provide complete remission in 80–90% of medically treated patients. However, the adverse effects of AEDs include drowsiness and dizziness, which interfere with patients' daily lives. For those with poor compatibility with AEDs, other treatment approaches are warranted.Case Report: A 19-year-old man presented to our institute with right hand and foot dyskinesia. He had a significant family history of PKD; his uncle, grandfather, and grandfather's brother had PKD. The patient first experienced paroxysmal involuntary left hand and toe flexion with left forearm pronation triggered by sudden voluntary movements at the age of 14. Carbamazepine (100 mg/day) was prescribed, which led to a significant reduction in the frequency of attacks. However, carbamazepine induced drowsiness, which significantly interfered with his daily life, especially school life. He underwent right-sided ventro-oral (Vo) thalamotomy at the age of 15, which resulted in complete resolution of PKD attacks immediately after the surgery. Four months after the thalamotomy, he developed right elbow, hand, and toe flexion. He underwent left-sided Vo thalamotomy at the age of 19. Immediately after the surgery, the PKD attacks resolved completely. However, mild dysarthria developed, which spontaneously resolved within three months. Left-sided PKD attacks never developed six years after the right Vo thalamotomy, and right-sided PKD attacks never developed two years after the left Vo thalamotomy without medication.Conclusion: The present case showed long-term suppression of bilateral PKDs after bilateral thalamotomy, which led to drug-free conditions.

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Bilateral staged magnetic resonance-guided focused ultrasound thalamotomy for the treatment of essential tremor: a case series study

Cited by 43 publications

References 9 publications

Bilateral Focused Ultrasound Thalamotomy for Essential Tremor (BEST‐FUS Phase 2 Trial)

Bilateral Focused Ultrasound Thalamotomy for Essential Tremor (BEST‐FUS Phase 2 Trial)

Bilateral Focused Ultrasound Pallidotomy for Parkinson‐Related Facial Dyskinesia—A Case Report

Case Report: Long-Term Suppression of Paroxysmal Kinesigenic Dyskinesia After Bilateral Thalamotomy

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