Imaging Findings in MR Imaging-Guided Focused Ultrasound Treatment for Patients with Essential Tremor

Wintermark, Max; Druzgal, T. Jason; Huss, Diane; Khaled, Mohamad; Monteith, Stephen J.; Raghavan, Prashant; Huerta, Thomas E.; Schweickert, L.C.; Burkholder, Brian; Loomba, Johanna; Zadicario, Eyal; Qiao, Yanbo; Shah, Binit; Snell, John; Eames, Matthew; Frysinger, Robert C.; Kassell, Neal F.; Elias, W. Jeff

doi:10.3174/ajnr.a3808

Cited by 130 publications

(135 citation statements)

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“…3. 28 Immediately posttreatment, the centroid of zone I was located at a mean 6.1 ± 0.9 mm anterior to the PC, 14.6 ± 0.8 mm lateral to the midline, and 11.0 ± 0.5 mm lateral to the border of the third ventricle at the level of the AC-PC plane (Table 2). At 24 hours posttreatment, the centroid of zone I appeared slightly more medial with a mean of 14.2 ± 0.6 mm (p = 0.015) lateral to the midline and 11.7 ± 0.6 mm (p = 0.009) lateral to the border of the third ventricle on the AC-PC plane.…”

Section: Lesion Locationmentioning

confidence: 99%

“…28 The authors separated the thalamotomy lesion into 3 concentric zones on T2-weighted imaginga hypointense center (necrotic core); a strongly hyperintense zone with a hypointense rim (cytotoxic edema); and a fuzzy, slightly hyperintense zone at the periphery (vasogenic edema)-and noted their similarity to stereotactic radiosurgery thalamotomies. They reported a relationship between lesion size, amount of perilesional edema, location, and tremor response in a series of 15 patients.…”

mentioning

confidence: 99%

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Volumetric analysis of magnetic resonance–guided focused ultrasound thalamotomy lesions

Harary¹,

Essayed²,

Valdés³

et al. 2018

Neurosurgical Focus

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OBJECTIVEMagnetic resonance–guided focused ultrasound (MRgFUS) thalamotomy was recently approved for use in the treatment of medication-refractory essential tremor (ET). Previous work has described lesion appearance and volume on MRI up to 6 months after treatment. Here, the authors report on the volumetric segmentation of the thalamotomy lesion and associated edema in the immediate postoperative period and 1 year following treatment, and relate these radiographic characteristics with clinical outcome.METHODSSeven patients with medication-refractory ET underwent MRgFUS thalamotomy at Brigham and Women’s Hospital and were monitored clinically for 1 year posttreatment. Treatment effect was measured using the Clinical Rating Scale for Tremor (CRST). MRI was performed immediately postoperatively, 24 hours posttreatment, and at 1 year. Lesion location and the volumes of the necrotic core (zone I) and surrounding edema (cytotoxic, zone II; vasogenic, zone III) were measured on thin-slice T2-weighted images using Slicer 3D software.RESULTSPatients had significant improvement in overall CRST scores (baseline 51.4 ± 10.8 to 24.9 ± 11.0 at 1 year, p = 0.001). The most common adverse events (AEs) in the 1-month posttreatment period were transient gait disturbance (6 patients) and paresthesia (3 patients). The center of zone I immediately posttreatment was 5.61 ± 0.9 mm anterior to the posterior commissure, 14.6 ± 0.8 mm lateral to midline, and 11.0 ± 0.5 mm lateral to the border of the third ventricle on the anterior commissure–posterior commissure plane. Zone I, II, and III volumes immediately posttreatment were 0.01 ± 0.01, 0.05 ± 0.02, and 0.33 ± 0.21 cm3, respectively. These volumes increased significantly over the first 24 hours following surgery. The edema did not spread evenly, with more notable expansion in the superoinferior and lateral directions. The spread of edema inferiorly was associated with the incidence of gait disturbance. At 1 year, the remaining lesion location and size were comparable to those of zone I immediately posttreatment. Zone volumes were not associated with clinical efficacy in a statistically significant way.CONCLUSIONSMRgFUS thalamotomy demonstrates sustained clinical efficacy at 1 year for the treatment of medication-refractory ET. This technology can create accurate, predictable, and small-volume lesions that are stable over time. Instances of AEs are transient and are associated with the pattern of perilesional edema expansion. Additional analysis of a larger MRgFUS thalamotomy cohort could provide more information to maximize clinical effect and reduce the rate of long-lasting AEs.

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Section: Lesion Locationmentioning

confidence: 99%

mentioning

confidence: 99%

Volumetric analysis of magnetic resonance–guided focused ultrasound thalamotomy lesions

Harary¹,

Essayed²,

Valdés³

et al. 2018

Neurosurgical Focus

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“…В той же группе пациентов было проведено исследо-вание динамики МР-характеристик очагов после ультра-звуковой vim-таламотомии, а также взаимосвязи этих па-раметров с клиническим эффектом [29]. По МРТ в режи-ме Т2 в первые сутки в очаге были выделены три концен-трические зоны: внутренняя зона 1 -гиперинтенсивная, промежуточная зона 2 -выраженно гипоинтенсивная и внешняя зона 3 -незначительно гиперинтенсивная.…”

Section: деструктивная нейромодуляцияunclassified

“…Признаков внутримозгового кровоизлияния не выявлено, однако в пределах зон 1 и 2 выявлялись про-дукты распада крови. Предполагается, что зоны 1 и 2 представлены коагуляционным некрозом и цитотокси-ческим отеком, зона 3 -вазогенным отеком [29][30][31]. …”

Section: деструктивная нейромодуляцияunclassified

“…Выраженность клинического эффекта была несколь-ко выше через 1 нед, когда размеры очага деструкции и отека были максимальны, и несколько уменьшалась через 1 и 3 мес, когда объем полости и перифокальный отек уменьшались [29]. Исчезновение видимой полости не оз-начало исчезновения клинического эффекта.…”

Section: обзорыunclassified

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The use of transcranial focused ultrasound in CNS diseases

Galkin

2016

Vopr. neirokhir.

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Транскраниальный фокусированный ультразвук -это современная медицинская технология, которая позволяет неинва-зивно оказывать воздействие на головной мозг. Современный этап развития этой методики насчитывает не более 20 лет и многие возможные приложения технологии находятся только на этапе доклинических исследований. Наибольший про-гресс достигнут в области функциональной нейрохирургии: фокусированный ультразвук позволяет неинвазивно под постоянным контролем МРТ создавать небольшие очаги деструкции в соответствующих мишенях, обеспечивая лечебные нейромодулирующие эффекты при болезни Паркинсона, эссенциальном треморе, болевых синдромах, обсессивно-ком-пульсивных расстройствах и других заболеваниях. На настоящий момент данное лечение проведено более чем у 300 пациентов. Опубликованы единичные случаи ультразвуковой термодеструкции интракраниальных новообразований. На животных проводятся попытки проведения ультразвуковой третьей вентрикулостомии. Отдельное направление посвя-щено увеличению проницаемости гематоэнцефалического барьера для различных веществ под воздействием фокусиро-ванного ультразвука. В лабораториях исследуется возможность увеличения проницаемости для химиопрепаратов, иммун-ных препаратов и других веществ. Большое количество работ направлено на лечение болезни Альцгеймера. Начаты кли-нические исследования увеличения проницаемости гематоэнцефалического барьера для химиопрепаратов. Еще одним недеструктивным эффектом, который в настоящее время активно исследуется на животных, является способность фоку-сированного ультразвука оказывать обратимое нейромодулирующее -стимулирующее и ингибирующее -действие на структуры нервной системы. Также в лабораторных исследованиях продемонстрирована способность фокусированного ультразвука разрушать сгустки крови и тромбы. Транскраниальный фокусированный ультразвук представляет множество уникальных возможностей для научной и прак-тической медицинской деятельности. Широкому внедрению в клинику будет предшествовать большая исследовательская работа. Тем не менее уже сейчас можно утверждать, что внедрение этой технологии значительно расширит диагностиче-ские и лечебные возможности в нейрохирургии и неврологии. Ключевые слова: ультразвук, фокусированный ультразвук, нейрохирургия, функциональная нейрохирургия, гематоэнцефалический барьер. The use of transcranial focused ultrasound in CNS diseases M.V. GALKIN Burdenko Neurosurgical Institute, Moscow, RussiaTranscranial focused ultrasound is a modern medical technique, which provides non-invasive impact on the brain. Current development stage of this technique is no longer than 20 years and many possible applications of this technique are still at preclinical stage. The greatest progress has been made in the field of functional neurosurgery. Focused ultrasound enables noninvasive MRI-guided formation of small destruction foci in the relevant targets, providing therapeutic neuromodulating effects in patients with Parkinson's disease, essential tremor, pain syndromes, obsessive-compulsive disorders, and other diseases. So far, thi...

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A Review of the Current Therapies, Challenges, and Future Directions of Transcranial Focused Ultrasound Technology

2018

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right-handed woman in her 90s presented with essential tremor involving bilateral arms, head, and voice. The tremors started 15 years ago and progressively became disabling. She had failed propranolol hydrochloride, primidone, and gabapentin, but she had an unremarkable medical history otherwise. Her examination revealed considerable symmetric tremor, with a Clinical Rating Scale for Tremor (score range: 0-132, with the highest score indicating severe tremor) score of 88 and scores of 38 in subscale A (at rest, posture, and action), 26 in subscale B (drawing spiral, handwriting), 24 in subscale C (quality-of-life), and 26 in subscales A and B (right-side tremor). The remainder of the neurological examina-tion results were unremarkable. Preoperative magnetic resonance imaging (MRI) revealed periventricular white-matter changes and mild age-related diffuse atrophy.After a multidisciplinary evaluation, she was not recommended for ventral intermediate nucleus (VIM) deep brain stimulation (DBS) due to her advanced age. Instead, she was offered focused ultrasound (FUS) thalamotomy. Computed tomography imaging determined that her skull was suitable for ultrasonographic treatment; her skull homogeneity was greater than 0.4, as calculated by skull density ratio (SDR, which is the median ratio of skull density between cortical and trabecular bone; higher SDR IMPORTANCE Magnetic resonance imaging-guided focused ultrasound ablation has been approved for the treatment of refractory essential tremor and is being studied for other neurological indications, including dyskinesias and tremor in Parkinson disease, dystonia, neuropathic pain, obsessive-compulsive disorder, epilepsy, and brain tumors. OBJECTIVE To review the scientific foundations of FUS technology, existing neurological applications, and future advances.EVIDENCE REVIEW PubMed was searched for the past 10 years using the terms "transcranial ultrasound," "focused ultrasound," and "neurological applications." Relevant references were selected from the author's reference collection. From the 2855 unique records, 243 publications were screened. After excluding abstracts detailing in vitro studies or non-neurological applications, 86 full texts were retrieved for qualitative review.FINDINGS Advances in the transducer design and electronic phase correction have allowed efficient focusing of ultrasounds for transcranial treatment. The mid-frequency (650 kHz) transducer can make small (4-6 mm in diameter) and precise (accuracy of <2 mm) brain lesions. The treatment monitoring is achieved via "live" anatomical thermography imaging and clinical feedback. The initial results from its clinical application in movement disorders are encouraging. Emerging applications in epilepsy and neurobehavioral and cognitive disorders are being explored. The low-frequency (220 kHz) transducer coupled with microbubbles can potentially enable targeted drug delivery for novel applications, such as Alzheimer disease and brain tumors. Finally, neuromodulation with subthreshold sonications may allow...

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Imaging Findings in MR Imaging-Guided Focused Ultrasound Treatment for Patients with Essential Tremor

Cited by 130 publications

References 28 publications

Volumetric analysis of magnetic resonance–guided focused ultrasound thalamotomy lesions

Volumetric analysis of magnetic resonance–guided focused ultrasound thalamotomy lesions

The use of transcranial focused ultrasound in CNS diseases

A Review of the Current Therapies, Challenges, and Future Directions of Transcranial Focused Ultrasound Technology

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