J Korean Neurosurg Soc.  2015 Mar;57(3):192-196. 10.3340/jkns.2015.57.3.192.

Outcome of Gamma Knife Thalamotomy in Patients with an Intractable Tremor

• Cho KR
• Kim HR
• Im YS
• Youn J
• Cho JW
• Lee JI

• KMID: 2191220
• DOI: http://doi.org/10.3340/jkns.2015.57.3.192

Abstract

OBJECTIVE
Tremor is a common movement disorder that interferes with daily living. Since the medication for tremor has some limitations, surgical intervention is needed in many patients. In certain patients who cannot undergo aggressive surgical intervention, Gamma Knife thalamotomy (GKT) is a safe and effective alternative.
METHODS
From June 2012 to August 2013, 7 patients with an intractable tremor underwent GKT. Four of these 7 patients had medical comorbidities, and 3 patients refused to undergo traditional surgery. Each patient was evaluated with the modified Fahn-Tolosa-Marin tremor rating scale (TRS) along with analysis of handwriting samples. All of the patients underwent GKT with a maximal dose of 130 Gy to the left ventralis intermedius (VIM) nucleus of the thalamus. Follow-up brain MRI was performed after 3 to 8 months of GKT, and evaluation with the TRS was also performed.
RESULTS
Six patients showed objective improvement in the TRS score. Excluding one patient who demonstrated tremor progression, there was 28.9% improvement in the TRS score. However, five patients showed subjective improvement in their symptoms. On comparing the TRS scores between follow-up periods of more and less than 4 months, the follow-up TRS score at more than 4 months of GKT was significantly improved compared to that at less than 4 months of GKT. Follow-up MRI showed radiosurgical changes in 5 patients.
CONCLUSION
GKT with a maximal dose of 130 Gy to the VIM is a safe procedure that can replace other surgical procedures.

Keyword

Gamma Knife; Thalamotomy; Ventralis intermedius; Tremor

MeSH Terms

Brain
Comorbidity
Follow-Up Studies
Handwriting
Humans
Magnetic Resonance Imaging
Movement Disorders
Thalamus
Tremor*

Figure

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  Fig. 1 Radiosurgical target was calculated with Surgiplan (Elekta AB, Stockholm, Sweden). Maximal dose of 130 Gy was applied to 93.6 mm2 area by using a single 4-mm collimator.

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  Fig. 2 Drawing a helical figure using both hands and writing a short sentence with the right hand was done prior to the procedure.

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  Fig. 3 Follow-up MRI at 4 months after Gamma Knife thalamotomy. Peripheral enhancing rim-like lesion was seen at the intended target site.

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  Fig. 4 Drawing a helical figure and writing a short sentence was performed at 10 months after Gamma Knife thalamotomy. Marked improvement in the right hand was seen. But, the patient still suffered tremor of the left hand.

Reference

1. Baizabal-Carvallo JF, Kagnoff MN, Jimenez-Shahed J, Fekete R, Jankovic J. The safety and efficacy of thalamic deep brain stimulation in essential tremor : 10 years and beyond. J Neurol Neurosurg Psychiatry. 2014; 85:567–572. PMID: 24096713.

2. Benabid AL, Pollak P, Gao D, Hoffmann D, Limousin P, Gay E, et al. Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg. 1996; 84:203–214. PMID: 8592222.

3. Fahn S TE, Marin C. Parkinson's Disease and Movement Disorders. ed 2. Baltimore: William & Wilkins;1993.

4. Fox MW, Ahlskog JE, Kelly PJ. Stereotactic ventrolateralis thalamotomy for medically refractory tremor in post-levodopa era Parkinson's disease patients. J Neurosurg. 1991; 75:723–730. PMID: 1919694.

5. Jankovic J, Cardoso F, Grossman RG, Hamilton WJ. Outcome after stereotactic thalamotomy for parkinsonian, essential, and other types of tremor. Neurosurgery. 1995; 37:680–686. discussion 686-687. PMID: 8559296.

6. Koller WC, Lyons KE, Wilkinson SB, Troster AI, Pahwa R. Long-term safety and efficacy of unilateral deep brain stimulation of the thalamus in essential tremor. Mov Disord. 2001; 16:464–468. PMID: 11391740.

7. Kondziolka D, Lunsford LD, Witt TC, Flickinger JC. The future of radiosurgery : radiobiology, technology, and applications. Surg Neurol. 2000; 54:406–414. PMID: 11240166.

8. Kondziolka D, Ong JG, Lee JY, Moore RY, Flickinger JC, Lunsford LD. Gamma Knife thalamotomy for essential tremor. J Neurosurg. 2008; 108:111–117. PMID: 18173319.

9. Lee JY, Kondziolka D. Thalamic deep brain stimulation for management of essential tremor. J Neurosurg. 2005; 103:400–403. PMID: 16235669.

10. Louis ED, Ottman R, Hauser WA. How common is the most common adult movement disorder? estimates of the prevalence of essential tremor throughout the world. Mov Disord. 1998; 13:5–10. PMID: 9452318.

11. Ohye C, Higuchi Y, Shibazaki T, Hashimoto T, Koyama T, Hirai T, et al. Gamma knife thalamotomy for Parkinson disease and essential tremor : a prospective multicenter study. Neurosurgery. 2012; 70:526–535. discussion 535-536. PMID: 21904267.

12. Pan L, Dai JZ, Wang BJ, Xu WM, Zhou LF, Chen XR. Stereotactic Gamma thalamotomy for the treatment of parkinsonism. Stereotact Funct Neurosurg. 1996; 66(Suppl 1):329–332. PMID: 9032876.

13. Pollak P, Benabid AL, Gervason CL, Hoffmann D, Seigneuret E, Perret J. Long-term effects of chronic stimulation of the ventral intermediate thalamic nucleus in different types of tremor. Adv Neurol. 1993; 60:408–413. PMID: 8420163.

14. Schuurman PR, Bosch DA, Bossuyt PM, Bonsel GJ, van Someren EJ, de Bie RM, et al. A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor. N Engl J Med. 2000; 342:461–468. PMID: 10675426.

15. Starr PA, Vitek JL, Bakay RA. Ablative surgery and deep brain stimulation for Parkinson's disease. Neurosurgery. 1998; 43:989–1013. discussion 1013-1015. PMID: 9802843.

16. Sydow O, Thobois S, Alesch F, Speelman JD. Multicentre European study of thalamic stimulation in essential tremor : a six year follow up. J Neurol Neurosurg Psychiatry. 2003; 74:1387–1391. PMID: 14570831.

17. Young RF, Jacques S, Mark R, Kopyov O, Copcutt B, Posewitz A, et al. Gamma knife thalamotomy for treatment of tremor : long-term results. J Neurosurg. 2000; 93(Suppl 3):128–135. PMID: 11143229.

18. Zhang K, Bhatia S, Oh MY, Cohen D, Angle C, Whiting D. Long-term results of thalamic deep brain stimulation for essential tremor. J Neurosurg. 2010; 112:1271–1276. PMID: 19911883.