Neurological adverse event profile of magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor.

BACKGROUND: Magnetic resonance imaging-guided focused ultrasound thalamotomy is approved by the U.S. Food and Drug Administration for treatment of essential tremor. Although this incisionless technology creates an ablative lesion, it potentially avoids serious complications of open stereotactic surgery. OBJECTIVE: To determine the safety profile of magnetic resonance imaging-guided focused ultrasound unilateral thalamotomy for essential tremor, including frequency, and severity of adverse events, including serious adverse events. METHODS: Analysis of safety data for magnetic resonance imaging-guided focused ultrasound thalamotomy (186 patients, five studies). RESULTS: Procedure-related serious adverse events were very infrequent (1.6%), without intracerebral hemorrhages or infections. Adverse events were usually transient and were commonly rated as mild (79%) and rarely severe (1%). As previously reported, abnormalities in sensation and balance were the commonest thalamotomy-related adverse events. CONCLUSION: The overall safety profile of magnetic resonance imaging-guided focused ultrasound thalamotomy supports its role as a new option for patients with medically refractory essential tremor. © 2018 International Parkinson and Movement Disorder Society.

Clinical improvement associated with targeted interruption of the cerebellothalamic tract following MR-guided focused ultrasound for essential tremor.

OBJECTIVE The objective of this study was to evaluate the utility of diffusion tensor imaging (DTI) tractography-based targeting of the dentatorubrothalamic tract (DRT) for magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy in patients with essential tremor (ET) and correlate postprocedural tract disruption with clinical outcomes. METHODS Four patients received preprocedural and immediate postprocedural DTI in addition to traditional anatomical MRI sequences for MRgFUS thalamotomy. Optimal ablation sites were selected based on the patient-specific location of the DRT as demonstrated by DTI (direct targeting) and correlated with traditional atlas-based measurements for thalamic ventral intermediate nucleus (Vim) lesioning (indirect targeting). Fiber tracts were displayed three-dimensionally during the procedure and used in conjunction with clinical signs of tremor control for fine correction of the ablation site. Immediately following the conclusion of the procedure, the MRgFUS head frame was removed and patients were placed in a 32-channel MRI head coil for follow-up DTI and anatomical MRI sequences. RESULTS All patients had excellent postoperative tremor control and successful pre- and postprocedural DTI fiber tracking of the corticospinal tract, medial lemniscus, and DRT. Immediate postprocedure DTI failed to track the DRT ipsilateral to the lesion site with a preserved contralateral DRT, coincident with substantial resolution of contralateral tremor. CONCLUSIONS DTI can reliably identify the optimal ablation target and demonstrates tract disruption on immediate postprocedural imaging. A clinical improvement of ET was observed immediately following the procedure, correlating with DRT disruption and suggesting that interruption of the DRT is a consequence of clinically successful MRgFUS thalamotomy. These findings may have utility for both MRgFUS procedure planning in surgically naive patients and retreatment of patients who have previously undergone unsuccessful thalamic Vim lesioning.

Gene transfer and in vivo promoter analysis of the rat progesterone receptor using a herpes simplex virus viral vector.

The progesterone receptor (PR) gene is expressed in cells of the anterior pituitary and hypothalamus, and PR levels are regulated by estrogen (E) in a tissue-specific fashion. To demonstrate that E induces transcription via the PR promoter, and to identify sequences within the PR promoter responsible for tissue-specific and hormonal regulation, we have utilized a defective herpes simplex virus vector for direct gene transfer into the rat pituitary and brain. We designed a viral amplicon expressing the beta-galactosidase gene under the regulation of a 2.1-kb PR promoter fragment to create a defective viral vector for gene transfer into the brain. Following injection of this vector into the pituitary and brain, its pattern of expression and ability to respond to estradiol 3-benzoate (EB) were examined. In the pituitary, lacZ activity was observed in cells of the anterior lobe (AL). However, no activity was seen in the neurointermediate lobe (NIL), demonstrating tissue specific transcriptional regulation. A approximately sixfold increase in cells demonstrating beta-galactosidase activity was observed in the AL following treatment with EB. Likewise, injection of defective viral vector into the hypothalamus followed by treatment with EB resulted in a approximately eightfold increase in cells demonstrating beta-galactosidase activity including the very cell groups responsible for EB-dependent reproductive behavior. In contrast, no vector dependent activity was observed in the caudate nucleus, a tissue with no endogenous expression of PR, despite polymerase chain reaction evidence demonstrating the presence of the vector in this tissue. These results demonstrate that the 2.1-kb PR promoter fragment contains the sequence information required for correct tissue and hormonal regulation of PR.