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GK thalamotomy for tremor treatment
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Medication is the predominant method for the management of patients with movement disorders. However, there is a fraction of patients who experience limited relief from pharmaceuticals or experience bothersome side-effects of the drugs. Deep brain stimulation (DBS) and surgical lesioning of the thalamus and basal ganglia are respected neurosurgical...
Context in source publication
Similar publications
Rationale:
Deep brain stimulation (DBS) of the ventralis intermedius nucleus (Vim) provides a safe and effective therapy for medically refractory essential tremor (ET). However, DBS may be risky in elderly patients and those with ischemic brain lesions. Gamma Knife radiosurgery (GKS) is a minimally invasive procedure, but bilateral thalamotomy is...
Thalamotomy at the ventralis intermedius nucleus has been an effective treatment method for essential tremor, but how the brain network changes immediately responding to this deliberate lesion and then reorganizes afterwards are not clear. Taking advantage of a non-cranium-opening MRI-guided focused ultrasound ablation technique, we investigated fu...
Background
Holmes tremor is a rare symptomatic movement disorder, characterized by a combination of resting, postural, and intention tremor. It is usually caused by lesions in the brainstem, thalamus, and cerebellum. Despite pharmacological advances, its treatment remains a challenge; many medications have been used with various degrees of effectiv...
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Background:
The cardinal features of Parkinson's disease (PD) are bradykinesia, rigidity and rest tremor. Abnormal activity in the basal ganglia is predicted to underlie the mechanism of motor symptoms. This study aims to characterize properties of oscillatory activity in the basal ganglia and motor thalamus in patients with PD.
Methods:
Twenty-...
Background:
Globus pallidus internus (GPi) deep brain stimulation (DBS) and thalamotomy are interventions for writer's cramp (WC). Ventralis intermedius nucleus (VIM) DBS is targeted for tremor, however, many aspects of VIM DBS remained underexplored in WC.
Case report:
A 62-year-old man with WC underwent DBS. Dystonic tremor improved intraopera...
Citations
... Various treatment modalities have been found for the treatment of movement disorders from invasive to less invasive such as chemical ablation using alcohol, radiofrequency lesioning, gamma knife radiosurgery, deep brain stimulation and magnetic resonance guided focused ultrasound surgery (MRgFUS) [7][8][9]. The complications of hemorrhage, infection, edema have been reported in various papers [3,4]. ...
Introduction and importance:
Ischemia associated with lesioning for the treatment of cervical dystonia is a very rare phenomenon. We reported a case of early internal capsule infarction following GPi lesioning for cervical dystonia.
Case presentation:
A 56-year-old man with one year history of progressive onset of cervical dystonia which was unresponsive to medical therapy. He was planned for bilateral globus pallidus internus pallidotomy. After completion of the procedure on one side and the successful completion of stimulation and test lesion on another side, the patient suddenly developed dysarthria and one sided weakness. Post-operative magnetic resonance imaging revealed acute infarction in the posterior end of the internal capsule. The patient was managed conservatively and underwent physiotherapy and rehabilitation care. He recovered gradually with modified ranking scale 3 on discharge.
Clinical discussion:
Globus pallidus internus lesioning or ablation is one of the surgical treatment for dystonia and movement disorder. Though considered as a safe technique, various risk are associated with the procedure. Ischemia is one of the associated risk but is a very rare phenomenon. Though the patient did not have any signs of pre-operative ischemia, the occlusion of one of the perforators to internal capsule during ablation may be the cause of intra-operative ischemia.
Conclusion:
Ischemia associated with lesioning in the treatment of cervical dystonia is a very rare phenomenon. Though, ischemia related with radiofrequency ablation is very rare and sporadic, one has to be very cautious during GPi pallidotomy to prevent occlusion of perforators to internal capsule.
... Bunun nedeni olarak da EARLYSTIM çalışmasına dâhil edilen hastaların genç olması, demansi psikiyatrik ve komorbid hastalıklarının olmaması ve yüksek levodopa cevabı olan hastalar olması gösterilmiştir(53). PH'da operasyon öncesi stimulasyonun etkinliğinin intraoperatif tam olarak değerlendirilmesi için anti parkinsonien ilaçlar operasyondan önce kesilmelidir(28,53).PH tedavisinde çeşitli kronik morbit hastalıklar ve oral antikoagulan kullanımı nedenli DBS ve radyofrekans cerrahisi yapılamayan hastalarda bir diğer cerrahi yöntem olan Gama Knife radyocerrahisi uygulanmaktadır(80).DBS'e göre daha non invaziv olması ve çok daha düşük komplikasyon oranı nedenli tercih edilebilen bu yöntemde özellikle Vim nörostimulasyonuna benzer şekilde Vim çekirdeğine gama knife uygulanmaktadır(81,82).Parkinson tremoru ve esansiyel tremor tedavisinde DBS kadar etkin olduğunu gösteren yayınlar mevcuttur. Bununla birlikte PH tedavisinde uygulanan STN ve GPi DBS işlemine göre etkinliğinın sınırlı olması ve geriye dönüşümsüz olması nedenli kullanım alanı sınırlıdır(80,81).Distoni: Distoni tedavisinde uzun süredir uygulanan pallidotomi yöntemi günümüzde uygulanmaya devam etmekleDemiryürek ve Barut. ...
... PH'da operasyon öncesi stimulasyonun etkinliğinin intraoperatif tam olarak değerlendirilmesi için anti parkinsonien ilaçlar operasyondan önce kesilmelidir(28,53).PH tedavisinde çeşitli kronik morbit hastalıklar ve oral antikoagulan kullanımı nedenli DBS ve radyofrekans cerrahisi yapılamayan hastalarda bir diğer cerrahi yöntem olan Gama Knife radyocerrahisi uygulanmaktadır(80).DBS'e göre daha non invaziv olması ve çok daha düşük komplikasyon oranı nedenli tercih edilebilen bu yöntemde özellikle Vim nörostimulasyonuna benzer şekilde Vim çekirdeğine gama knife uygulanmaktadır(81,82).Parkinson tremoru ve esansiyel tremor tedavisinde DBS kadar etkin olduğunu gösteren yayınlar mevcuttur. Bununla birlikte PH tedavisinde uygulanan STN ve GPi DBS işlemine göre etkinliğinın sınırlı olması ve geriye dönüşümsüz olması nedenli kullanım alanı sınırlıdır(80,81).Distoni: Distoni tedavisinde uzun süredir uygulanan pallidotomi yöntemi günümüzde uygulanmaya devam etmekleDemiryürek ve Barut. Hareket Bozuklukları Cerrahisi X birlikte DBS birçok distoni alt tipinde kullanılmaktadır(28). Distoni tedavisinde bilateral GPi nörostimulasyonu PH' a bağlı distoni ve jeneralize distonide yapılmaktadır(32).Son yıllardaki çalışmalarda GPi nörostimulasyonu jeneralize distonisi olan olgularda bradikinezi ortaya çıkardığını belirten yayınlar mevcuttur bu nedenle distoni tedavisinde diğer basal ganglia yapılarına DBS yapılması gündeme gelmiştir. ...
Movement disorders display complex pathophysiologies. The first step in their management is medical treatment. However, if medical treatment is an inadequate or cannot be used because of side effects, surgical treatment should be considered. Surgery is used to treat essential tremors, Parkinson disease, and dystonia. There are two types of surgery currently available: lesioning and neurostimulation. A method called DBS is more preferable than lesioning because its outcomes are reversible and it has a low ratio of morbidity. However, conservative surgical approaches continue to be used for treating some movement disorders. This review discusses lesioning and neurostimulation in the treatment of movement disorders.
... Patients can be treated in a minimally invasive fashion and return to usual activities the next day. GKRS has found applications as a primary strategy or adjuvant therapy in a number of clinical fields including intracranial tumors, vascular malformations, psychiatric disorders, and functional disorders such as pain, movement disorder, and epilepsy (21)(22)(23)(24)(25). Despite risks of radiation-induced adverse effects, GKRS is now an indispensable neurosurgical tool, especially in cases where the lesion is too hard to approach with standard neurosurgery and the patient's condition not good enough to endure open surgery (26). ...
Image-guided neurosurgery (IGN) is a technique for localizing objects of surgical interest within the brain. In the past, its main use was placement of electrodes; however, the advent of computed tomography has led to a rebirth of IGN. Advances in computing techniques and neuroimaging tools allow improved surgical planning and intraoperative information. IGN influences many neurosurgical fields including neuro-oncology, functional disease, and radiosurgery. As development continues, several problems remain to be solved. This article provides a general overview of IGN with a brief discussion of future directions.
... 6,12 Although Gamma Knife radiosurgery, especially in Gamma Knife thalamotomy, have achieved an efficacy similar to RF lesioning for movement disorders, there are important issues to consider, including the time interval between treatment and effect, variability of the target area reaction, and inability to predict side effects for specific patients. 4,17 Furthermore, the complication rate associated with Gamma Knife radiosurgery in patients with movement disorders has been reported to be as high as 50%, although the reported complications were not fatal. ...
Objective:
Magnetic resonance-guided focused ultrasound surgery (MRgFUS) was recently introduced as treatment for movement disorders such as essential tremor and advanced Parkinson's disease (PD). Although deep brain target lesions are successfully generated in most patients, the target area temperature fails to increase in some cases. The skull is one of the greatest barriers to ultrasonic energy transmission. The authors analyzed the skull-related factors that may have prevented an increase in target area temperatures in patients who underwent MRgFUS.
Methods:
The authors retrospectively reviewed data from clinical trials that involved MRgFUS for essential tremor, idiopathic PD, and obsessive-compulsive disorder. Data from 25 patients were included. The relationships between the maximal temperature during treatment and other factors, including sex, age, skull area of the sonication field, number of elements used, skull volume of the sonication field, and skull density ratio (SDR), were determined.
Results:
Among the various factors, skull volume and SDR exhibited relationships with the maximum temperature. Skull volume was negatively correlated with maximal temperature (p = 0.023, r(2) = 0.206, y = 64.156 - 0.028x, whereas SDR was positively correlated with maximal temperature (p = 0.009, r(2) = 0.263, y = 49.643 + 11.832x). The other factors correlate with the maximal temperature, although some factors showed a tendency to correlate.
Conclusions:
Some skull-related factors correlated with the maximal target area temperature. Although the number of patients in the present study was relatively small, the results offer information that could guide the selection of MRgFUS candidates.
... In 1997, The Food and Drug Administration approved DBS of the thalamus as a management approach for parkinsonian and essential tremor [2]. Since that time, numerous published series have reported positive results when using DBS for tremor relief [3]. Although it has proven to be a successful treatment, DBS puts the patient at risk for pulmonary embolism, subcortical hemorrhage, venous infarction, seizure, cerebrospinal fluid leak, skin erosion, and death [2]. ...
... Although it has proven to be a successful treatment, DBS puts the patient at risk for pulmonary embolism, subcortical hemorrhage, venous infarction, seizure, cerebrospinal fluid leak, skin erosion, and death [2]. In addition, DBS is contraindicated for patients who have advanced cardiac or respiratory disease, who use anticoagulants, and who are of advanced age [3]. ...
Patients who suffer from tremors are initially treated with pharmecuticals. Although medication has proven to be effective in achieving tremor control for some patients, there is still a fraction of patients who seek neurosurgical alternatives due to unacceptable tremor relief or side-effects from the prescribed drugs. Invasive neurosurgical procedures include radiofrequency thalamotomy and in recent years deep brain stimulation. However, patients who have advanced cardiac or respiratory disease, patients who use anticoagulants and patients who are of advanced age are not qualified candidates for neurosurgery. An alternative modality for lesioning intracranial structures is stereotactic radiosurgery using the Gamma Knife. The Gamma Knife is a Cobalt-60 based machine, with 201 separate 4 to18 mm collimator openings that emits multiple gamma rays that converge on a focal point in the brain specified by computer planning. Since its introduction by Leksell, the role of Gamma Knife radiosurgery as a management approach for patients diagnosed with tremors is continuously increasing. This article will review the efficacy of GKRS in the management of tremors, as well as describe the treatment planning and methods associated with this evolving treatment strategy.
Deep brain stimulation (DBS) is a medical treatment that aims at obtaining therapeutic effects by applying chronic electrical impulses in specific brain structures. The saga started in 1947 with the development of a stereotactic device for application in the human brain and the publication of reliable stereotactic brain atlases. These developments made it possible to induce precision lesions in deep brain structures solely through a burr hole in the skull. Following this, lesion surgery was replaced by chronic high-frequency electrical stimulation. DBS had been used since the 1950s for treatment of psychiatric patients, but this practice was abandoned due to ethical objections, as well as the introduction of neuroleptics. In the 1960s, the technique had been introduced for treatment of movement disorders. In 1993, DBS had been acknowledged for the treatment of tremors and thereafter for the treatment of Parkinson’s disease, dystonias, obsessive–compulsive disorder and epilepsy.
Targeted therapeutic surgical lesioning for Parkinson disease has a history extending over 100 years, involving almost every level of the central nervous system often with serendipitous discovery of therapeutic approaches. Despite a near abandonment of lesioning for Parkinson disease after the introduction of levodopa, a resurgence of interest in lesioning was appreciated after recognizing limitations of medications over time in some patients. While the introduction of deep brain stimulation has made lesioning second-line treatment in some parts of the world, unilateral stereotactic lesioning remains an effective and viable option for therapeutic intervention, particularly in an era with incisionless approaches for targeted lesioning.
Diepe hersenstimulatie (‘deep brain stimulation’, DBS) is een behandeling waarbij door middel van chronische elektrische stroompulsen in bepaalde hersengebieden therapeutische effecten kunnen worden bereikt. Deze behandelmethode heeft zich vooral kunnen ontwikkelen door de introductie van het stereotaxieapparaat in 1947 en de publicatie van betrouwbare stereotaxieatlassen. Hierdoor werd het mogelijk in bepaalde hersenstructuren gericht laesies aan te brengen. Later werd het aanbrengen van laesies vervangen door permanente hoogfrequente stimulatie van specifieke hersenstructuren. Stimulatie werd sinds de jaren vijftig van de vorige eeuw toegepast bij psychiatrische indicaties, maar verloor door ethische bezwaren en de introductie van neuroleptica weer snel aan terrein. In de jaren zestig van de vorige eeuw werden de eerste behandelingen bij bewegingsstoornissen uitgevoerd. DBS verkreeg in 1997 erkenning voor de behandeling van tremoren, later gevolgd voor de indicaties ziekte van Parkinson, dystonieën, obsessieve-compulsieve stoornis en epilepsie.
Medication is the first line of treatment for patients who suffer from tremors. Even though many patients are able to manage their condition with pharmaceuticals, there is still a fraction of patients who seek neurosurgical alternatives due to unacceptable tremor relief or side-effects from the prescribed drugs. According to the wealth of world literature, deep brain stimulation (DBS) has largely replaced radiofrequency thalamotomy as the primary neurosurgical modality for patients diagnosed with tremors. However, there is a subset of patients who are not qualified candidates for DBS. This population of patients consists of those who have advanced cardiac or respiratory disease, those who use anticoagulants, those who are of advanced age, and those who are known to be noncompliant. Stereotactic radiosurgery using the Gamma Knife (GK) is a minimally-invasive treatment alternative and has proven to be effective for patients who are contraindicated from DBS. The GK is a Cobalt-60 based machine, with 201 separate 4 to18 mm collimator openings that emits multiple gamma rays that converge on a focal point in the brain specified by computer planning. Since its introduction by Professor Lars Leksell, the role of Gamma Knife radiosurgery (GKRS) in the treatment of patients with tremors is continuously evolving. This chapter will review the efficacy of GKRS in the management of tremors, as well as describe the treatment planning and methods associated with GK thalamotomy.
Movement disorders have a long history of treatment with ablative or destructive procedures dating back to 1890 when Sir Victor Horsley performed an extirpation of the motor cortex for the treatment of athetosis. There was a great decline in the number of surgical cases when carbidopa/levodopa became popularized in 1968. Over time, we have discovered that medications have their limitations resulting in the resurgence of surgery for movement disorders. There are several surgical options available including high-intensity focused ultrasound, Gamma Knife, radiofrequency ablation, and deep brain stimulation. All but deep brain stimulation result in irreversible destruction of tissue. Deep brain stimulation has been proven to be a safe, efficient, and reversible tool to help movement neurologists optimize their patients’ quality of life. Currently, it is the therapeutic treatment of choice for refractory disorders. There are essential differences between deep brain stimulation and the ablative modalities, and each has its pros and cons. It this chapter, we will try to précis each modality and compare in between. We will also review the evidence for both deep brain stimulation and radiosurgery. We hope that the readers of this chapter will be able to use it as a tool in making better treatment decisions for their patients.
