Clinical improvement associated with targeted interruption of the cerebellothalamic tract following MR-guided focused ultrasound for essential tremor

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OBJECTIVE

The objective of this study was to evaluate the utility of diffusion tensor imaging (DTI) tractography–based targeting of the dentatorubrothalamic tract (DRT) for magnetic resonance–guided focused ultrasound (MRgFUS) thalamotomy in patients with essential tremor (ET) and correlate postprocedural tract disruption with clinical outcomes.

METHODS

Four patients received preprocedural and immediate postprocedural DTI in addition to traditional anatomical MRI sequences for MRgFUS thalamotomy. Optimal ablation sites were selected based on the patient-specific location of the DRT as demonstrated by DTI (direct targeting) and correlated with traditional atlas-based measurements for thalamic ventral intermediate nucleus (Vim) lesioning (indirect targeting). Fiber tracts were displayed three-dimensionally during the procedure and used in conjunction with clinical signs of tremor control for fine correction of the ablation site. Immediately following the conclusion of the procedure, the MRgFUS head frame was removed and patients were placed in a 32-channel MRI head coil for follow-up DTI and anatomical MRI sequences.

RESULTS

All patients had excellent postoperative tremor control and successful pre- and postprocedural DTI fiber tracking of the corticospinal tract, medial lemniscus, and DRT. Immediate postprocedure DTI failed to track the DRT ipsilateral to the lesion site with a preserved contralateral DRT, coincident with substantial resolution of contralateral tremor.

CONCLUSIONS

DTI can reliably identify the optimal ablation target and demonstrates tract disruption on immediate postprocedural imaging. A clinical improvement of ET was observed immediately following the procedure, correlating with DRT disruption and suggesting that interruption of the DRT is a consequence of clinically successful MRgFUS thalamotomy. These findings may have utility for both MRgFUS procedure planning in surgically naive patients and retreatment of patients who have previously undergone unsuccessful thalamic Vim lesioning.

ABBREVIATIONS AC-PC = anterior commissure-posterior commissure; CRST = combined rating scale for tremor; CST = corticospinal tract; DBS = deep brain stimulation; DRT = dentatorubrothalamic tract; DTI = diffusion tensor imaging; ET = essential tremor; ML = medial lemniscus; MMSE = mini-mental state examination; MRgFUS = magnetic resonance–guided focused ultrasound; QSM = quantitative susceptibility mapping; SWI = susceptibility-weighted imaging; Vim = ventral intermediate nucleus.
Article Information

Contributor Notes

Correspondence Michael G. Kaplitt, Department of Neurosurgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, 525 East 68th St., Box 99, New York, NY 10065. email: mik2002@med.cornell.edu.INCLUDE WHEN CITING Published online October 20, 2017; DOI: 10.3171/2017.4.JNS162803.Disclosures Financial support for this study was provided by Insightec (Haifa, Israel).
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