A Randomized Trial of Focused Ultrasound Thalamotomy for Essential Tremor.

BACKGROUND: Uncontrolled pilot studies have suggested the efficacy of focused ultrasound thalamotomy with magnetic resonance imaging (MRI) guidance for the treatment of essential tremor. METHODS: We enrolled patients with moderate-to-severe essential tremor that had not responded to at least two trials of medical therapy and randomly assigned them in a 3:1 ratio to undergo unilateral focused ultrasound thalamotomy or a sham procedure. The Clinical Rating Scale for Tremor and the Quality of Life in Essential Tremor Questionnaire were administered at baseline and at 1, 3, 6, and 12 months. Tremor assessments were videotaped and rated by an independent group of neurologists who were unaware of the treatment assignments. The primary outcome was the between-group difference in the change from baseline to 3 months in hand tremor, rated on a 32-point scale (with higher scores indicating more severe tremor). After 3 months, patients in the sham-procedure group could cross over to active treatment (the open-label extension cohort). RESULTS: Seventy-six patients were included in the analysis. Hand-tremor scores improved more after focused ultrasound thalamotomy (from 18.1 points at baseline to 9.6 at 3 months) than after the sham procedure (from 16.0 to 15.8 points); the between-group difference in the mean change was 8.3 points (95% confidence interval [CI], 5.9 to 10.7; P<0.001). The improvement in the thalamotomy group was maintained at 12 months (change from baseline, 7.2 points; 95% CI, 6.1 to 8.3). Secondary outcome measures assessing disability and quality of life also improved with active treatment (the blinded thalamotomy cohort)as compared with the sham procedure (P<0.001 for both comparisons). Adverse events in the thalamotomy group included gait disturbance in 36% of patients and paresthesias or numbness in 38%; these adverse events persisted at 12 months in 9% and 14% of patients, respectively. CONCLUSIONS: MRI-guided focused ultrasound thalamotomy reduced hand tremor in patients with essential tremor. Side effects included sensory and gait disturbances. (Funded by InSightec and others; ClinicalTrials.gov number, NCT01827904.).

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.

Posttraumatic hemidystonia treated with unilateral globus pallidus interna stimulation: Long-term follow-up and radiologic features.

OBJECTIVE: Hemidystonia is a unilateral clinical presentation of dystonia, and it is usually refractory to current methods of medical treatment. Recently, deep brain stimulation has given some hope of recovery to dystonic patients. MATERIALS AND METHODS: A 30-year-old right-handed man with no abnormal perinatal history or family history of movement disorders was admitted to our institution. The patient had suffered right-sided dystonia for more than three years after severe head trauma sustained four years prior. RESULTS: We performed a stereotactic implantation of an electrode into the left globus pallidus internus (GPi) and he showed excellent response to pallidal stimulation during long-term follow-up. CONCLUSIONS: We present a unique case of secondary posttraumatic hemidystonia treated with contralateral GPi stimulation with an excellent outcome. Pallidal stimulation can be a good treatment option for posttraumatic hemidystonia in selected cases.

Gamma band activity associated with BCI performance: simultaneous MEG/EEG study.

While brain computer interface (BCI) can be employed with patients and healthy subjects, there are problems that must be resolved before BCI can be useful to the public. In the most popular motor imagery (MI) BCI system, a significant number of target users (called "BCI-Illiterates") cannot modulate their neuronal signals sufficiently to use the BCI system. This causes performance variability among subjects and even among sessions within a subject. The mechanism of such BCI-Illiteracy and possible solutions still remain to be determined. Gamma oscillation is known to be involved in various fundamental brain functions, and may play a role in MI. In this study, we investigated the association of gamma activity with MI performance among subjects. Ten simultaneous MEG/EEG experiments were conducted; MI performance for each was estimated by EEG data, and the gamma activity associated with BCI performance was investigated with MEG data. Our results showed that gamma activity had a high positive correlation with MI performance in the prefrontal area. This trend was also found across sessions within one subject. In conclusion, gamma rhythms generated in the prefrontal area appear to play a critical role in BCI performance.

Reoperation for persistent or recurrent hemifacial spasm after microvascular decompression.

OBJECTIVE: The objective of this study was to investigate the outcome of reoperation for persistent or recurrent hemifacial spasm (HFS) after microvascular decompression (MVD). METHODS: Repeat MVD was performed on 13 patients with an HFS between June 1994 and May 2004. Patients who had compressing offending vessels identified on postoperative (prerevision) three-dimensional short-range magnetic resonance angiography were selected for repeat MVD. RESULTS: Six patients were found to have no improvement in HFS with the first MVD. All of these patients exhibited excellent improvement after the second MVD. In one patient who had mild improvement with the first MVD, but with more than 50% of remaining spasm, complete abolition of spasm occurred immediately after the second MVD. Six patients showed initial relief and subsequent aggravation of HFS after the first MVD. Of these patients, four had excellent results with the second MVD, one had a good result, and one had a fair outcome. Adverse effects after the second MVD were found in two patients (one patient with permanent mild facial weakness and one patient with hearing impairment). There was no serious morbidity associated with the second MVD. CONCLUSION: Our data suggest that repeat MVD of the facial nerve may be sufficient to resolve symptoms in selected patients with persistent or recurrent HFS. Additionally, three-dimensional short-range magnetic resonance angiography may help to identify the offending vessels and to select the patients with persistent or recurrent HFS.