Impact of skull density ratio on efficacy and safety of magnetic resonance–guided focused ultrasound treatment of essential tremor

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  • 1 Departments of Neurosurgery and
  • | 2 Radiology, Stanford University School of Medicine, Stanford, California;
  • | 3 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;
  • | 4 University of Maryland School of Medicine, Baltimore, Maryland;
  • | 5 Swedish Neuroscience Institute, Seattle, Washington;
  • | 6 Tokyo Women’s Medical University, Tokyo, Japan;
  • | 7 Yonsei University College of Medicine, Seoul, Korea;
  • | 8 Sunnybrook Health Sciences Center, Toronto, Ontario, Canada;
  • | 9 The Ohio State University Medical Center, Columbus, Ohio;
  • | 10 Washoukai Sadamoto Hospital, Matsuyama City, Japan;
  • | 11 Kumamoto University Hospital, Obihiro City, Japan;
  • | 12 Osaka University Hospital, Osaka, Japan;
  • | 13 Brigham and Women’s Hospital, Boston, Massachusetts;
  • | 14 ResoFUS Alomar, Barcelona, Spain;
  • | 15 Weill Cornell School of Medicine, New York, New York;
  • | 16 Nara Medical University, Kashihara, Japan;
  • | 17 St. Mary’s Hospital, London, United Kingdom; and
  • | 18 InSightec, Ltd., Dallas, Texas
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OBJECTIVE

Skull density ratio (SDR) assesses the transparency of the skull to ultrasound. Magnetic resonance–guided focused ultrasound (MRgFUS) thalamotomy in essential tremor (ET) patients with a lower SDR may be less effective, and the risk for complications may be increased. To address these questions, the authors analyzed clinical outcomes of MRgFUS thalamotomy based on SDRs.

METHODS

In 189 patients, 3 outcomes were correlated with SDRs. Efficacy was based on improvement in Clinical Rating Scale for Tremor (CRST) scores 1 year after MRgFUS. Procedural efficiency was determined by the ease of achieving a peak voxel temperature of 54°C. Safety was based on the rate of the most severe procedure-related adverse event. SDRs were categorized at thresholds of 0.45 and 0.40, selected based on published criteria.

RESULTS

Of 189 patients, 53 (28%) had an SDR < 0.45 and 20 (11%) had an SDR < 0.40. There was no significant difference in improvement in CRST scores between those with an SDR ≥ 0.45 (58% ± 24%), 0.40 ≤ SDR < 0.45 (i.e., SDR ≥ 0.40 but < 0.45) (63% ± 27%), and SDR < 0.40 (49% ± 28%; p = 0.0744). Target temperature was achieved more often in those with an SDR ≥ 0.45 (p < 0.001). Rates of adverse events were lower in the groups with an SDR < 0.45 (p = 0.013), with no severe adverse events in these groups.

CONCLUSIONS

MRgFUS treatment of ET can be effectively and safely performed in patients with an SDR < 0.45 and an SDR < 0.40, although the procedure is more efficient when SDR ≥ 0.45.

ABBREVIATIONS

CRST = Clinical Rating Scale for Tremor; ET = essential tremor; FUS = focused ultrasound; MRgFUS = magnetic resonance–guided focused ultrasound; SDR = skull density ratio.

Illustration from Ivan et al. (pp 1517–1528). Copyright Kenneth Probst. Published with permission.

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