Stereotactic radiosurgery for tremor: systematic review

International Stereotactic Radiosurgery Society practice guidelines

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The aim of this systematic review is to offer an objective summary of the published literature relating to stereotactic radiosurgery (SRS) for tremor and consensus guideline recommendations.


This systematic review was performed up to December 2016. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The following key words were used: “radiosurgery” and “tremor” or “Parkinson’s disease” or “multiple sclerosis” or “essential tremor” or “thalamotomy” or “pallidotomy.” The search strategy was not limited by study design but only included key words in the English language, so at least the abstract had to be in English.


A total of 34 full-text articles were included in the analysis. Three studies were prospective studies, 1 was a retrospective comparative study, and the remaining 30 were retrospective studies. The one retrospective comparative study evaluating deep brain stimulation (DBS), radiofrequency thermocoagulation (RFT), and SRS reported similar tremor control rates, more permanent complications after DBS and RFT, more recurrence after RFT, and a longer latency period to clinical response with SRS. Similar tremor reduction rates in most of the reports were observed with SRS thalamotomy (mean 88%). Clinical complications were rare and usually not permanent (range 0%–100%, mean 17%, median 2%). Follow-up in general was too short to confirm long-term results.


SRS to the unilateral thalamic ventral intermediate nucleus, with a dose of 130–150 Gy, is a well-tolerated and effective treatment for reducing medically refractory tremor, and one that is recommended by the International Stereotactic Radiosurgery Society.

ABBREVIATIONS DBS = deep brain stimulation; ET = essential tremor; FTMRS = Fahn-Tolosa-Marin rating scale; GKRS = Gamma Knife radiosurgery; PD = Parkinson’s disease; RFT = radiofrequency thermocoagulation; SRS = stereotactic radiosurgery; UPDRS = Unified Parkinson’s Disease Rating Scale; VIM = ventral intermediate nucleus.

Article Information

Correspondence Nuria E. Martínez-Moreno: Ruber International Hospital, Madrid, Spain.

INCLUDE WHEN CITING Published online February 23, 2018; DOI: 10.3171/2017.8.JNS17749.

Disclosures Dr. Sahgal: honoraria for past educational seminars from Medtronic, Elekta AB, Accuray Inc., and Varian Medical Systems; and research grants from Elekta AB. Dr. Slotman: research grant and speaker honorarium from Varian Medical Systems, and speaker honorarium from ViewRay. Dr. Paddick: consultant for Elekta Instruments AB. Dr. Régis: support of non–study-related clinical or research effort. Dr. Martínez-Álvarez: consultant to Elekta AB.

© AANS, except where prohibited by US copyright law.



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    Flow diagram showing the selection of studies for the systematic review of radiosurgical treatment of tremor.

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    MR images showing target localization of the VIM.

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    MR images showing changes 1 year after GKRS thalamotomy (maximum dose 130 Gy). A and B: Axial (A) and coronal (B) Gd-enhanced T1-weighted images showing a millimetric lesion measuring a few millimeters that correlates with the 91-Gy isodose line. C: Sagittal T1-weighted image showing a low-signal region that coincides with the 91-Gy isodose line.

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    Levels of evidence summary based on details provided by the Oxford Centre for Evidence-Based Medicine ( The original levels of evidence were produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, and Martin Dawes beginning in November 1998. The latest update (March 2009) is by Jeremy Howick.



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