Magnetic resonance guided focused ultrasound thalamotomy for essential tremor

Magnetic resonance guided focused ultrasound thalamotomy for essential tremor

Magnetic resonance guided focused ultrasound is a minimally invasive surgical procedure for symptomatic treatment of Parkinson Disease. With this technology, the ventral intermediate nucleusSTN, and internal globus pallidus have been targeted for therapeutic cerebral ablation, while also minimizing the risk of hemorrhage and infection from more invasive neurosurgical procedures.

In a pilot study published in 2013, essential tremor improved in 15 patients treated with magnetic resonance guided focused ultrasound thalamotomy1).

Clinical trials have confirmed the efficacy of focused ultrasound (FUS) thalamotomy in essential tremor, but its effectiveness and safety for managing tremor-dominant Parkinson disease (TDPD) is unknown.

It might change the way that patients with essential tremor and potentially other disorders are treated 2).

Effectiveness

The post-treatment effectiveness was evaluated using the clinical rating scale for tremors. Thalamic MRgHIFU had substantial therapeutic effects on patients, based on MRgHIFU-mediated improvements in movement control and significant changes in brain mu rhythms. Ultrasonic thalamotomy may reduce hyper-excitable activity in the motor cortex, resulting in normalized behavioral activity after sonication treatment. Thus, non-invasive and spatially accurate MRgHIFU technology can serve as a potent therapeutic tool with broad clinical applications 3).

Safety

Magnetic resonance guided focused ultrasound (MRgFUS) for thalamotomy is a safe, effective and less-invasive surgical method for treating medication-refractory essential tremor (ET). However, several issues must be resolved before clinical application of MRgFUS, including optimal patient selection and management of patients during treatment 4).

Jung et al. found different MRI pattern evolution after MRgFUS for white matter and gray matter. Their results suggest that skull characteristics, such as low skull density, should be evaluated prior to MRgFUS to successfully achieve thermal rise 5).

Nursing management

In a large academic medical center in the mid-Atlantic region, the Department of Neurosurgery conducted a continued access study, recently approved by the Food and Drug Administration, to evaluate the effectiveness of transcranial FUS thalamotomy for the treatment of medication-refractory ET.

One patient’s experience will be introduced, including discussion of evidence-based treatment options for ET and information on the nursing management of the patient undergoing FUS thalamotomy 6).

Prospective randomized clinical trials

In a double-blinded, prospective, sham-controlled randomized controlled trial of MR-guided focused ultrasound thalamotomy for treatment of tremor-dominant PD, 62% of treated patients demonstrated improvement in tremor scores from baseline to 3 months postoperatively, as compared to 22% in the sham group. There has been only one open-label trial of MR-guided focused ultrasound subthalamotomy for patients with PD, demonstrating improvements of 71% for rigidity, 36% for akinesia, and 77% for tremor 6 months after treatment. Among the two open-label trials of MR-guided focused ultrasound pallidotomy for patients with PD, dyskinesia and overall motor scores improved up to 52% and 45% at 6 months postoperatively. Although MR-guided focused ultrasound thalamotomy is now approved by the U.S. Food and Drug Administration for treatment of parkinsonian tremor, additional high-quality randomized controlled trials are warranted and are underway to determine the safety and efficacy of MR-guided focused ultrasound subthalamotomy and pallidotomy for treatment of the cardinal features of PD. These studies will be paramount to aid clinicians to determine the ideal ablative target for individual patients. Additional work will be required to assess the durability of MR-guided focused ultrasound lesions, ideal timing of MR-guided focused ultrasound ablation in the course of PD, and the safety of performing bilateral lesions 7).

Case series

References

1)

Elias WJ, Huss D, Voss T, Loomba J, Khaled M, Zadicario E, Frysinger RC, Sperling SA, Wylie S, Monteith SJ, Druzgal J, Shah BB, Harrison M, Wintermark M. A pilot study of focused ultrasound thalamotomy for essential tremor. N Engl J Med. 2013 Aug 15;369(7):640-8. doi: 10.1056/NEJMoa1300962. PubMed PMID: 23944301.
2)

Lipsman N, Schwartz ML, Huang Y, Lee L, Sankar T, Chapman M, Hynynen K, Lozano AM. MR-guided focused ultrasound thalamotomy for essential tremor: a proof-of-concept study. Lancet Neurol. 2013 May;12(5):462-8. doi: 10.1016/S1474-4422(13)70048-6. Epub 2013 Mar 21. PubMed PMID: 23523144.
3)

Chang JW, Min BK, Kim BS, Chang WS, Lee YH. Neurophysiologic correlates of sonication treatment in patients with essential tremor. Ultrasound Med Biol. 2015 Jan;41(1):124-31. doi: 10.1016/j.ultrasmedbio.2014.08.008. Epub 2014 Oct 22. PubMed PMID: 25438838.
4)

Chang WS, Jung HH, Kweon EJ, Zadicario E, Rachmilevitch I, Chang JW. Unilateral magnetic resonance guided focused ultrasound thalamotomy for essential tremor: practices and clinicoradiological outcomes. J Neurol Neurosurg Psychiatry. 2015 Mar;86(3):257-64. doi: 10.1136/jnnp-2014-307642. Epub 2014 May 29. PubMed PMID: 24876191.
5)

Jung HH, Chang WS, Rachmilevitch I, Tlusty T, Zadicario E, Chang JW. Different magnetic resonance imaging patterns after transcranial magnetic resonance-guided focused ultrasound of the ventral intermediate nucleus of the thalamus and anterior limb of the internal capsule in patients with essential tremor or obsessive-compulsive disorder. J Neurosurg. 2015 Jan;122(1):162-8. doi: 10.3171/2014.8.JNS132603. PubMed PMID: 25343176.
6)

Shaw KD, Johnston AS, Rush-Evans S, Prather S, Maynard K. Nursing Management of the Patient Undergoing Focused Ultrasound: A New Treatment Option for Essential Tremor. J Neurosci Nurs. 2017 Aug 16. doi: 10.1097/JNN.0000000000000301. [Epub ahead of print] PubMed PMID: 28817495.
7)

Moosa S, Martínez-Fernández R, Elias WJ, Del Alamo M, Eisenberg HM, Fishman PS. The role of high-intensity focused ultrasound as a symptomatic treatment for Parkinson’s disease. Mov Disord. 2019 Jul 10. doi: 10.1002/mds.27779. [Epub ahead of print] Review. PubMed PMID: 31291491.

Book: Essential Clinical Handbook for Neurosurgery (Essential Clinical Handbooks)

Essential Clinical Handbook for Neurosurgery (Essential Clinical Handbooks)
By Jon Sen

Essential Clinical Handbook for Neuro (Essential Clinical Handbooks)

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This is a neurosurgical text that is current, accessible, practical, insightful and authoritative, a companion guide that will act as a comprehensive resource for trainees at all levels, from junior specialty registrars sitting the MRCS to those undertaking their final exit exams (FRCS (SN). It includes clear signposting along the way indicating what objectives need to be met at each level. The content has been structured to provide a learner friendly approach to this complex subject matter. It adopts a step-by-step guide to progressively more complex neurosurgical procedures, as well as including the most up-to-date research that will impact on practice for years to come. This concise textbook distils everything a modern neurosurgery trainee needs to know. It is also suitable for those training in the United States, working towards their primary and final ABN exams. The book will also be of interest as a reference source for practicing neurologists, GP medical students and other healthcare professionals with an interest in this field.


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  • Published on: 2016-09-30
  • Original language: English
  • Number of items: 1
  • Dimensions: 8.27″ h x .87″ w x 5.91″ l, .0 pounds
  • Binding: Paperback
  • 200 pages

New Book: Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Exam

Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Exam

By Vivian A. Elwell, Ramez Kirollos, Syed Al-Haddad

Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Exam

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 Product Description

Neurosurgery: The Essential Guide to the Oral and Clinical Neurosurgical Examination is the first book of its kind to cover the International and Intercollegiate FRCS Specialty Examination in Neurosurgery. It will also help you prepare for the American Board of Neurological Surgery (ABNS) examination and other neurosurgical examinations around the world. Written by neurosurgeons, this book is a hands-on guide that translates basic science and theories of neurosurgery into clinical practice. This comprehensive resource takes a standardized and logical approach to the clinical neurosurgical examination. Based on the authors’ own clinical practice, teaching and examination experiences, this book provides candidates with a firm grasp of neuroscience and the ability to solve problems under pressure.
Scenario- and patient-based, the book covers history-taking, clinical examination, differential diagnosis, investigations, management, treatment options and potential complications. The text is based on the Royal College of Surgeons of England and U.S. board syllabuses. In addition to serving as a reliable preparation resource for the neurosurgical examination, it will also be invaluable in your future surgical practice.


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  • Amazon Sales Rank: #485213 in Books
  • Published on: 2014-12-16
  • Original language: English
  • Number of items: 1
  • Dimensions: 9.69″ h x .35″ w x 7.44″ l,
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  • 181 pages

Editorial Reviews

About the Author
Miss Vivian A. Elwell is currently working as a Post-CCT Senior Spinal Fellow at The National Hospital for Neurology and Neurosurgery in London. Miss Elwell’s awards include the Swinford Edward Silver Medal Prize for her OSCE Examination; the Columbia University Research Fellowship at Columbia College of Physicians and Surgeons in New York City, USA; the Columbia University King’s Crown Gold and Silver Medal Awards; the Kathrine Dulin Folger Cancer Research Fellowship and the ‘Who’s Who Young Scientists Award’. In 2010, she was a finalist for the BMA’s Junior Doctor of the Year Award. Miss Elwell received her BA from Columbia College, Columbia University, and her MA from the University of Cambridge. She earned a Bachelor of Medicine and Bachelor of Surgery from the Imperial College School of Medicine. She is a Fellow of the Royal College of Surgeons.
Mr Ramez Kirollos is a Consultant Neurosurgeon at Addenbrooke’s Hospital in Cambridge. His main clinical interests include anterior and middle skull base, pituitary and pineal surgery, and surgical treatment of arteriovenous malformations. A passion for neurosurgical technique based on the thorough understanding of anatomy has accompanied Mr Kirollos’ neurosurgical training and forms the basis of his surgical practice. Dr Kirollos oversees weekly registrar teaching sessions at Addenbrooke’s Hospital, and serves on the faculty for Neuroanatomy of Operative Approaches and the British Neurosurgical Trainee. In 2006, Dr Kirollos was elected as a member of the Court of Examiners of the Royal College of Surgeons of England. In 2010, for his commitment to surgical education, he received the prestigious Silver Scalpel Award. He is the chairman of the British Neurovascular Group (2013-2015).
Mr Syed Al-Haddad is a Consultant Neurosurgeon at Aberdeen Royal Infirmary, Scotland. He commenced his neurosurgical training at the Walton Centre in Liverpool, where he developed his interest in neuro-oncology research. He undertook further training in neurosurgery in Manchester, Leeds, Aberdeen and Edinburgh. He has been actively involved in teaching both undergraduate and postgraduate students and is a faculty member for Leeds and Edinburgh operative neuroanatomy courses. He has published numerous articles in peer-reviewed journals. Mr Al-Haddad is the founder and director of the highly successful Aberdeen FRCS (SN) Viva course, which gives practical advice to neurosurgeons preparing for the challenge of the neurosurgical exam.

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