Prospective Tractography-Based Targeting for Improved Safety of Focused Ultrasound Thalamotomy. Issue 1 (21st March 2018)

• Record Type: Journal Article
• Authors: Krishna, Vibhor; Sammartino, Francesco; Agrawal, Punit; Changizi, Barbara K; Bourekas, Eric; Knopp, Michael V; Rezai, Ali
• Is Part Of: Neurosurgery. Volume 84:Issue 1(2019)
• Page Start: 160
• Page End: 168
• Publication Date: 2018-03-21
• Subjects: Focused ultrasound -- Tractography -- Tremor -- Thalamus -- Outcomes -- Targeting; Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyy020
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: BACKGROUND: Focused ultrasound thalamotomy (FUS-T) was recently approved for the treatment of refractory essential tremor (ET). Despite its noninvasive approach, FUS-T reinitiated concerns about the adverse effects and long-term efficacy after lesioning. OBJECTIVE: To prospectively assess the outcomes of FUS-T in 10 ET patients using tractography-based targeting of the ventral intermediate nucleus (VIM). METHODS: VIM was identified at the intercommissural plane based on its neighboring tracts: the pyramidal tract and medial lemniscus. FUS-T was performed at the center of tractography-defined VIM. Tremor outcomes, at baseline and 3 mo, were assessed independently by the Tremor Research Group. We analyzed targeting coordinates, clinical outcomes, and adverse events. The FUS-T lesion location was analyzed in relation to unbiased thalamic parcellation using probabilisitic tractography. Quantitative diffusion-weighted imaging changes were also studied in fiber tracts of interest. RESULTS: The tractography coordinates were more anterior than the standard. Intraoperatively, therapeutic sonications at the tractography target improved tremor (>50% improvement) without motor or sensory side effects. Sustained improvement in tremor was observed at 3 mo (tremor score: 18.3 ± 6.9 vs 8.1 ± 4.4, P = .001). No motor weakness and sensory deficits after FUS-T were observed during 6-mo follow-up. Ataxia was observed in 3 patients. FUS-T lesions overlapped with the VIM parcellated with probablisitic tractography. Significant microstructural changes were observed in the white matter connecting VIM with cerebellum and motor cortex. CONCLUSION: This is the first report of prospective VIM targeting with tractography for FUS-T. These results suggest that tractography-guided targeting is safe and has satisfactory short-term clinical outcomes.