Gamma Knife thalamotomy for tremor in the magnetic resonance imaging era

Clinical article

Ali KooshkabadiDepartments of Neurological Surgery and

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 M.D.
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L. Dade LunsfordDepartments of Neurological Surgery and

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 M.D.
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Daniel TonettiDepartments of Neurological Surgery and

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 M.S.
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John C. FlickingerDepartments of Neurological Surgery and
Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

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 M.D.
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Douglas KondziolkaDepartments of Neurological Surgery and
Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

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 M.D., M.Sc.
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Object

The surgical management of disabling tremor has gained renewed vigor with the availability of deep brain stimulation. However, in the face of an aging population of patients with increasing surgical comorbidities, noninvasive approaches for tremor management are needed. The authors' purpose was to study the technique and results of stereotactic radiosurgery performed in the era of MRI targeting.

Methods

The authors evaluated outcomes in 86 patients (mean age 71 years; number of procedures 88) who underwent a unilateral Gamma Knife thalamotomy (GKT) for tremor during a 15-year period that spanned the era of MRI-based target selection (1996–2011). Symptoms were related to essential tremor in 48 patients (19 age ≥ 80 years and 3 age ≥ 90 years), Parkinson disease in 27 patients (11 age ≥ 80 years [1 patient underwent bilateral procedures]), and multiple sclerosis in 11 patients (1 patient underwent bilateral procedures). A single 4-mm isocenter was used to deliver a maximum dose of 140 Gy to the posterior-inferior region of the nucleus ventralis intermedius. The Fahn-Tolosa-Marin clinical tremor rating scale was used to grade tremor, handwriting, and ability to drink. The median follow-up was 23 months.

Results

The mean tremor score was 3.28 ± 0.79 before and 1.81 ± 1.15 after (p < 0.0001) GKT; the mean handwriting score was 2.78 ± 0.82 and 1.62 ± 1.04, respectively (p < 0.0001); and the mean drinking score was 3.14 ± 0.78 and 1.80 ± 1.15, respectively (p < 0.0001). After GKT, 57 patients (66%) showed improvement in all 3 scores, 11 patients (13%) in 2 scores, and 2 patients (2%) in just 1 score. In 16 patients (19%) there was a failure to improve in any score. Two patients developed a temporary contralateral hemiparesis, 1 patient noted dysphagia, and 1 sustained facial sensory loss.

Conclusions

Gamma Knife thalamotomy in the MRI era was a safe and effective noninvasive surgical strategy for medically refractory tremor in the elderly or those with contraindications to deep brain stimulation or stereotactic radiofrequency (thermal) thalamotomy.

Abbreviations used in this paper:

AC = anterior commissure; DBS = deep brain stimulation; ET = essential tremor; FTM = Fahn-Tolosa-Marin; GKT = Gamma Knife thalamotomy; MS = multiple sclerosis; PC = posterior commissure; PD = Parkinson disease; RFT = radiofrequency thalamotomy; VIM = ventralis intermedius.
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