Functional outcomes after gamma knife thalamotomy for essential tremor and MS-related tremor

Niranjan, Ajay; Kondziolka, Douglas; Baser, Susan; Heyman, Rock; Lunsford, L. Dade

doi:10.1212/wnl.55.3.443

Cited by 94 publications

(48 citation statements)

References 11 publications

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“…100 In one retrospective study (class IV), gamma knife treatment resulted in complete tremor arrest in 75% of patients (n ϭ 9), and all patients benefited subjectively from the procedure. 98 There were significant improvements in drawing capability at follow-up (median of 6 months). The onset of improvement occurred at a median of 6 weeks following the procedure, and additional improvements continued for the next 6 months.…”

Section: What Are the Indications For Bilateral Vs Unilateral Surgicamentioning

confidence: 92%

“…Electrophysiologic guidance is not possible. Several studies (n ϭ 61) have reported favorable results with gamma knife thalamotomy, 98,99 although one case report documented delayed side effects from the procedure including contralateral arm numbness and dysarthria. 100 In one retrospective study (class IV), gamma knife treatment resulted in complete tremor arrest in 75% of patients (n ϭ 9), and all patients benefited subjectively from the procedure.…”

Section: What Are the Indications For Bilateral Vs Unilateral Surgicamentioning

confidence: 99%

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Practice Parameter: Therapies for essential tremor [RETIRED]

et al. 2005

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Abstract-Background: Essential tremor (ET) is one of the most common tremor disorders in adults and is characterized by kinetic and postural tremor. To develop this practice parameter, the authors reviewed available evidence regarding initiation of pharmacologic and surgical therapies, duration of their effect, their relative benefits and risks, and the strength of evidence supporting their use. Methods: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 1966 and August 2004. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. Results and Conclusions: Propranolol and primidone reduce limb tremor (Level A). Alprazolam, atenolol, gabapentin (monotherapy), sotalol, and topiramate are probably effective in reducing limb tremor (Level B). Limited studies suggest that propranolol reduces head tremor (Level B). Clonazepam, clozapine, nadolol, and nimodipine possibly reduce limb tremor (Level C). Botulinum toxin A may reduce hand tremor but is associated with dose-dependent hand weakness (Level C). Botulinum toxin A may reduce head tremor (Level C) and voice tremor (Level C), but breathiness, hoarseness, and swallowing difficulties may occur in the treatment of voice tremor. Chronic deep brain stimulation (DBS) (Level C) and thalamotomy (Level C) are highly efficacious in reducing tremor. Each procedure carries a small risk of major complications. Some adverse events from DBS may resolve with time or with adjustment of stimulator settings. There is insufficient evidence regarding the surgical treatment of head and voice tremor and the use of gamma knife thalamotomy (Level U). Additional prospective, double-blind, placebo-controlled trials are needed to better determine the efficacy and side effects of pharmacologic and surgical treatments of ET.

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Section: What Are the Indications For Bilateral Vs Unilateral Surgicamentioning

confidence: 92%

Section: What Are the Indications For Bilateral Vs Unilateral Surgicamentioning

confidence: 99%

Practice Parameter: Therapies for essential tremor [RETIRED]

et al. 2005

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“…Since the first 1992 publication, 12 several studies [13][14][15][16][17] have reported the efficacy of GK thalamotomy (GKT) on severe tremor (essential tremor [ET] and tremor-dominant Parkinson disease [PD]) with a low rate of complications. However, as highlighted in a recent review, 18 the level of evidence is weak and suffers from being mainly based on retrospective cohort studies, a single prospective study with no independent evaluation, and only one single-blind study on 14 patients.…”

mentioning

confidence: 99%

“…However, as highlighted in a recent review, 18 the level of evidence is weak and suffers from being mainly based on retrospective cohort studies, a single prospective study with no independent evaluation, and only one single-blind study on 14 patients. [13][14][15][16][17]19 These studies comprise significant flaws. 2,18 An accurate independent and blinded assessment of tremor control is a critical step in determining whether the procedure is successful.…”

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confidence: 99%

A prospective single-blind study of Gamma Knife thalamotomy for tremor

et al. 2015

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Objective: To evaluate the safety and efficacy of unilateral Gamma Knife thalamotomy (GKT) for treatment of severe tremor with a prospective blinded assessment.Methods: Fifty patients (mean age: 74.5 years; 32 men) with severe refractory tremor (36 essential, 14 parkinsonian) were treated with unilateral GKT. Targeting of the ventral intermediate nucleus (Vim) was achieved with Leksell Gamma Knife with a single shot through a 4-mm collimator helmet. The prescription dose was 130 Gy. Neurologic and neuropsychological assessments including a single-blinded video assessment of the tremor severity performed by a movement disorders neurologist from another center were performed before and 12 months after treatment. MRI follow-up occurred at 3, 6, and 12 months. Results:The upper limb tremor score improved by 54.2% on the blinded assessment (p , 0.0001). All tremor components (rest, postural, and intention) were improved. Activities of daily living were improved by 72.2%. Cognitive functions remained unchanged. Following GKT, the median delay of improvement was 5.3 months (range 1-12 months). The only side effect was a transient hemiparesis associated with excessive edema around the thalamotomy in one patient. Conclusion:This blinded prospective assessment demonstrates that unilateral GKT is a safe and efficient procedure for severe medically refractory tremor. Side effects were rare and transient in this study. Classification of evidence:This study provides Class IV evidence that for patients with severe refractory tremor, GKT is well tolerated and effective in reducing tremor impairment. The pharmacologic treatment for severe tremor can be disappointing.

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“…1). The authors of several studies have reported success rates in tremor control in patients with PD, essential tremor, and tremor related to multiple sclerosis or other causes 13,17,41,42,43,51,68,69,72 that are comparable to those achieved using other methods. Complications are usually rare, mild, and temporary, although unusual complications 62 and severe, permanent complications 47 have also been reported.…”

Section: Treatment Of Tremorsmentioning

confidence: 91%

Stereotactic radiosurgery for functional disorders

Friehs

Park

Goldman

et al. 2007

FOC

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✓ Stereotactic radiosurgery (SRS) with the Gamma Knife and linear accelerator has revolutionized neurosurgery over the past 20 years. The most common indications for radiosurgery today are tumors and arteriovenous malformations of the brain. Functional indications such as treatment of movement disorders or intractable pain only contribute a small percentage of treated patients. Although SRS is the only noninvasive form of treatment for functional disorders, it also has some limitations: neurophysiological confirmation of the target structure is not possible, and one therefore must rely exclusively on anatomical targeting. Furthermore, lesion sizes may vary, and shielding adjacent radiosensitive neural structures may be difficult or impossible. The most common indication for functional SRS is the treatment of trigeminal neuralgia. Radiosurgical treatment for epilepsy and certain psychiatric illnesses is performed in several centers as part of strict research protocols, and radiosurgical pallidotomy or medial thalamotomy is no longer recommended due to the high risk of complications. Radiosurgical ventrolateral thalamotomy for the treatment of tremor in patients with Parkinson disease or multiple sclerosis, as well as in the treatment of essential tremor, may be indicated for a select group of patients with advanced age, significant medical conditions that preclude treatment with open surgery, or patients who must receive anticoagulation therapy. A promising new application of SRS is high-dose radiosurgery delivered to the pituitary stalk. This treatment has already been successfully performed in several centers around the world to treat severe pain in patients with end-stage cancer.

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Functional outcomes after gamma knife thalamotomy for essential tremor and MS-related tremor

Cited by 94 publications

References 11 publications

Practice Parameter: Therapies for essential tremor [RETIRED]

Practice Parameter: Therapies for essential tremor [RETIRED]

A prospective single-blind study of Gamma Knife thalamotomy for tremor

Stereotactic radiosurgery for functional disorders

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