Functional lesional neurosurgery for tremor: back to the future?

Abstract

For nearly a century, functional neurosurgery has been applied in the treatment of tremor. While deep brain stimulation has been in the focus of academic interest in recent years, the establishment of incisionless technology, such as MRI-guided high-intensity focused ultrasound, has again stirred interest in lesional approaches.In this article, we will discuss the historical development of surgical technique and targets, as well as the technological state-of-the-art of conventional and incisionless interventions for tremor due to Parkinson's disease, essential and dystonic tremor and tremor related to multiple sclerosis (MS) and midbrain lesions. We will also summarise technique-inherent advantages of each technology and compare their lesion characteristics. From this, we identify gaps in the current literature and derive future directions for functional lesional neurosurgery, in particularly potential trial designs, alternative targets and the unsolved problem of bilateral lesional treatment. The results of a systematic review and meta-analysis of the consistency, efficacy and side effect rate of lesional treatments for tremor are presented separately alongside this article.

Botulinum toxin for the treatment of hand tremor

“…Deep brain stimulation (DBS) is a highly effective treatment for tremor in ET and PD, but is invasive and can be associated with stimulationinduced and long-term side effects [12,13]. Functional lesional neurosurgery, especially focused ultrasound, has garnered more interest recently in the treatment of tremor but this intervention is not readily available and is associated with potentially serious adverse effects, particularly when performed bilaterally [14][15][16]. Botulinum toxin (BoNT) has been increasingly used in the treatment of focal tremors with reported good outcomes and long-term safety [17,18].…”

“…Using a similar study design, the same authors performed incoBoNT-A injections in 28 patients (of 33 enrolled) with hand ET [25]. IncoBoNT-A were injected into a mean of 9 (range, [8][9][10][11][12][13][14] hand and forearm muscles (80-120 U). IncoBoNT-A treatment led to significant reduction of tremor (FTM tremor rating scale part B and the National Institute of Health Collaborative Genetic Criteria tremor score severity) at weeks 4 and 8 (p < 0.05).…”

Complete Resolution of Symptoms of Primary Orthostatic Tremor with Perampanel

“…Perampanel—which prevents excitation of post-synaptic membranes by inhibiting the glutamate receptors—may therefore modulate flows in reciprocal circuits with abnormal oscillatory neuronal activity and, in this way, significantly regulate tremor amplitude, even though the primary pacemaker may not modify high tremor frequency. 18 – 20 …”

Neuroimaging advances in Parkinson's disease: Erratum

“…Both deep brain stimulating and advanced lesioning [74] rely on the correct pre-surgical identification of target structures. One report proposed STN visualization to benefit from using QSM over T2*-weighted images [75] (see Figure 3).…”