Cutoff values for the best management strategy for magnetic resonance–guided focused ultrasound ablation for essential tremor

Jun ToriiDepartment of Neurosurgery, Nagoya University Graduate School of Medicine;

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Satoshi MaesawaDepartment of Neurosurgery, Nagoya University Graduate School of Medicine;

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Daisuke NakatsuboDepartment of Neurosurgery, Nagoya University Graduate School of Medicine;
Focused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital;

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Takahiko TsugawaFocused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital;
Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospital;

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Sachiko KatoFocused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital;
Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospital;

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Tomotaka IshizakiDepartment of Neurosurgery, Kainan Hospital;

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Sou TakaiDepartment of Neurosurgery, Ichinomiya Municipal Hospital; and

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Masashi ShibataFocused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital;
Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospital;

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Toshihiko WakabayashiFocused Ultrasound Therapy Center, Nagoya Kyoritsu Hospital;

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Takashi TsuboiDepartment of Neurology, Nagoya University Graduate School of Medicine, Aichi, Japan

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Masashi SuzukiDepartment of Neurology, Nagoya University Graduate School of Medicine, Aichi, Japan

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Ryuta SaitoDepartment of Neurosurgery, Nagoya University Graduate School of Medicine;

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OBJECTIVE

The efficacy of magnetic resonance–guided focused ultrasound (MRgFUS) ablation for essential tremor (ET) is well known; however, no prognostic factors have been established. The authors aimed to retrospectively investigate MRgFUS ablation outcomes and associated factors and to define the cutoff values for each prognostic factor.

METHODS

Sixty-four Japanese patients who underwent unilateral ventral intermediate nucleus thalamotomy with MRgFUS for ET were included. Follow-up evaluations were performed at 1 week and 1, 3, 6, 12, and 24 months postoperatively. Tremor suppression was evaluated using the Clinical Rating Scale for Tremor (CRST), and adverse effects were recorded postoperatively. Outcome-associated factors were examined preoperatively, intraoperatively, and postoperatively using multivariate analyses. The cutoff values for the prognostic factors were calculated using receiver operating characteristics.

RESULTS

Percentage improvements in the CRST scores of the affected upper limb were 82.4%, 72.2%, 68.6%, and 65.9% at 1, 3, 6, and 12 months, respectively. Preoperatively, a high skull density ratio (SDR) (p ≤ 0.047), low CRST part B score (used to assess tremors during several tasks) (cutoff value 25, p ≤ 0.041), and nonoccurrence of resting tremors (p = 0.027) were significantly associated with improved tremor control. An intraoperatively high maximum mean temperature (cutoff value 52.5°C, p ≤ 0.047), postoperatively large lesion (cutoff value 3.9 mm in the anterior-posterior direction, p ≤ 0.002; cutoff value 5.0–5.55 mm in the superior-inferior direction, p ≤ 0.026), and small transducer focus correction (p ≤ 0.015) were also associated with improved tremor control. No valid cutoff value was found for SDR. Adverse effects (limb weakness, sensory disturbance, ataxia/walking disturbance, dysgeusia, dysarthria, and facial swelling) occurred transiently and were associated with high SDR, high temperature, high number of sonication sessions, large lesion, and occurrence of resting tremor. Patients who developed leg weakness experienced greater percentage improvement in tremors at 3 months postoperatively than those who did not.

CONCLUSIONS

MRgFUS ablation could be used to achieve good tremor control with acceptable adverse effects in Japanese patients with ET. The relatively low SDR in Asian ethnic groups as compared with that of Western populations makes treatment difficult; however, the cutoff values obtained in this study may be useful for achieving good treatment outcomes even in such patients.

Clinical trial registration no.: UMIN000026952 (University Hospital Medical Information Network)

ABBREVIATIONS

ACPC = anterior commissure–posterior commissure; AP = anterior to posterior; CRST = Clinical Rating Scale for Tremor; ET = essential tremor; MRgFUS = magnetic resonance–guided focused ultrasound; PC = posterior commissure; PSA = posterior subthalamic area; RL = right to left; ROC = receiver operating characteristic; SDR = skull density ratio; SI = superior to inferior; T2WI = T2-weighted imaging; VIM = ventral intermediate nucleus.
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Figure from Ramos et al. (pp 95–103).

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