Stereotactic ventrolateral thalamotomy in the treatment of essential tremor

BACKGROUND AND PURPOSE: Essential tremor is the most common tremorogenic movement disorder. In the majority of patients the progression of the disease is slow and the pharmacological treatment effectively alleviates tremor. In rare cases of increased essential tremor the surgical treatment (ventrolateral thalamotomy) is indicated. The goal of this study was to assess the effectiveness of unilateral thalamotomy in the treatment of essential tremor. MATERIAL AND METHODS: 10 stereotactic ventrolateral thalamotomies were performed in 9 patients for pharmacologically intractable essential tremor. Right thalamotomy was done in 5 patients and left thalamotomy in 4 patients. The study included five men and four women. Patients were assessed according to the Clinical Rating Scale for Tremor (CRST) before surgery and at 3, 12 and 24 months after thalamotomy. RESULTS: In the postoperative period there was a marked reduction of essential tremor in the contralateral arm and, to a lower extent, in the contralateral leg. The mean presurgery value for contralateral upper extremity postural tremor (scores 5/6 CRST) decreased from 3.5 to mean postsurgery value of 0.6. The tremor reduction contributed to 59% improvement in specific motor tasks of upper extremities (Part B of CRST) at 2 years follow-up. There was also improvement of functional disabilities (Part C of CRST) by 62% when compared to preoperative value 2 years postoperatively. CONCLUSIONS: Ventrolateral thalamotomy is a highly effective method in the treatment of essential tremor. The side effects related to surgery are rare and most of them are transient.     

Stereotactic ventrolateral thalamotomy in the treatment of Holmes tremor

BACKGROUND AND PURPOSE: The authors report the results of stereotactic surgery for severe posttraumatic tremor in 7 patients. MATERIAL AND METHODS: All patients were severely incapacitated in their daily living activities by mainly kinetic and postural components of Holmes tremor. The 7 patients underwent 8 stereotactic operations. The stereotactic target in all patients was the ventrolateral thalamus. Patients were evaluated using the Clinical Rating Scale For Tremor (CRST) before and up to 24 months after stereotactic thalamotomy. RESULTS: In the postoperative period there was marked amelioration in kinetic and postural components of Holmes tremor in contralateral upper and lower extremity. The mean presurgery value for contralateral upper extremity kinetic tremor (scores 5-6 CRST) dropped from 3.25 to mean postsurgery value of 0.5. There was also a marked functional improvement. It was reduced from a mean value of 71% of maximum disability according to CRST (scores 15-21, part C CRST, 0% independent, 100% total dependent) to 28.5% over 2-year follow-up. CONCLUSIONS: Ventrolateral thalamotomy alleviates effectively Holmes tremor and improves greatly performance of activities of daily living.     

Stereotactic selective thalamotomy for the treatment of tremor type cerebral palsy in adolescence

6 cases with tremor-athetotic type cerebral palsy and 2 cases with moderate dystonia-tremor type cerebral palsy were treated by selective stereotactic thalamotomy. In the former group, postural-movement type tremor in the upper limb gradually progressed with age while athetosis remained unchanged. In the latter group, dystonia in the truncal muscles predominated over the irregular tremulous movement of the upper limbs. In all cases, the intelligence was almost normal. Stereotactic selective thalamotomy (Vim for tremor athetosis, VL-Vim for dystonia tremor) was performed under local anesthesia with the aid of radiological and neurophysiological control methods. The results of the operations were satisfactory in regard to the tremor relief and concomitant improvement of motor performances in most of the cases. Stereotactic treatment might be an effective way to make possible a one-step progress in these handicapped cases. The importance of postoperative physical therapy is also emphasized.     

Stereotactic thalamotomy for the relief of intention tremor of multiple sclerosis.

The results of a stereotactic thalamotomy in 11 patients with clinically definite multiple sclerosis and severe intention tremor are discussed. The operation produces a beneficial effect on the tremor and an improvement of arm function in most patients. The good results have often been counterbalanced by postoperative complications or progression of the disease. An operation may be considered, if the tremor lasts for at least a year, and if there is no serious cerebral atrophy or other relevant damage to CNS structures. The patient must be capable of giving informed consent.     

Stereotactic pallidotomy and thalamotomy in the treatment of primary dystonia

BACKGROUND AND PURPOSE: The goal of the study was to assess the results of the stereotactic pallidotomy and thalamotomy in the treatment of primary dystonia. MATERIAL AND METHODS: Thirty patients with primary dystonia underwent twenty-eight stereotactic pallidotomies and twenty two thalamotomies. The operations were based on the fused images of computed tomography and magnetic resonance imaging, and were verified by an intraoperative neurophysiological investigation. Neurological and neuropsychological assessments were performed before surgery and at 3 days, 3 and 6 months after the operation. The Mann-Whitney U test was used to find out statistic differences between subgroups and the Wilcoxon test to compare results between particular assessments. RESULTS: The statistic analysis showed postsurgical amelioration of the neurological state lasting at least 6 months. A better long-term outcome was revealed in the subgroup of pallidotomies vs. thalamotomies, in the subgroup with the onset of dystonia after the age of 35 vs. earlier onset, and in the subgroup of the focal and local dystonia vs. generalized dystonia. The statistically significant improvement was achieved at a depression level and the statistically significant deterioration was not stated in the mental status after the operations. A very low percentage of neurological complications after the operations was found in the study. CONCLUSIONS: The stereotactic pallidotomies and thalamotomies are effective and safe options in the treatment of the intractable cases of primary dystonia. Both resulted predominantly in contralateral improvement of motor functions. However, the results of pallidotomies are better than thalamotomies six months after the surgery. The improvement of the mood without cognitive deterioration was revealed in the neuropsychological tests after the operations. Only few, persistent and mild complications were ascertained in the study.     

立体定向下丘脑Vim核毁损术治疗特发性震颤的相关因素分析

目的探讨立体定向下丘脑腹中间核(Vim核)毁损术治疗特发性震颤(essentialtremor,ET)的疗效及相关因素。方法回顾性分析微电极导向下单侧丘脑毁损术治疗的55例ET患者。对患者术前术后肢体震颤、生活功能改善情况进行评估,对并发症、症状复发及手术适应证进行分析。结果手术对侧肢体震颤完全消失47例,遗留有轻微震颤8例,头颈、躯干部震颤及声音震颤有所改善,同侧肢体震颤无缓解,震颤的整体改善率54.1%,术后复发3例,同侧二次手术后震颤完全控制。长期随访疗效稳定,患者生活质量明显提高。一过性并发症15例,无永久性并发症。结论立体定向单侧Vim核毁损术治疗ET是一种安全、有效的方法,微电极引导准确定位是手术成功的保障,症状复发及并发症的出现与靶点定位不准及毁损灶大小有关。     

Unilateral thalamotomy for the treatment of tremor dominant Parkinson's disease

BACKGROUND AND PURPOSE: To assess the effectiveness of unilateral thalamotomy for the treatment of parkinsonian tremor and other motor signs of Parkinson's disease (PD). MATERIAL AND METHODS: Between 1999 and 2004, 41 patients with idiopathic tremor dominant PD were treated surgically in the Neurosurgical Department of Postgraduate Medical Center in Warsaw. Stereotactic thalamotomy was performed with Leksell stereotactic frame (model G) using intraoperative macrostimulation. The patients were assessed according to the Unified Parkinson's Disease Rating Scale version 3. (UPDRS) before and after thalamotomy in the off state. The progression of PD was also evaluated according to the Hoehn and Yahr scale in the off state and also Schwab and England was used to assess the disability of the patients. The patients were evaluated before thalamotomy in the off state, and 3, 12, 24 and 36 months after surgery, according to the above mentioned clinical rating scales. RESULTS: The authors report their results among 41 patients who underwent stereotactic thalamotomy 3 years postoperatively. At 3 years follow-up (in the group of 19 patients) the contralateral tremor from the presurgical value of 11.2 (items 20 - 21 UPDRS) decreased to 2.6. The rigidity in contralateral limbs at 3 years follow-up was 1.7 (item 22 UPDRS) when compared to 2.8 (item 22 UPDRS) preoperative value. Thalamotomy had no effect on bradykinesia or other manifestations of PD such as balance or gait disturbance. There were 13 transient and 6 permanent complications. CONCLUSIONS: Thalamotomy using intraoperative macrostimulation in carefully selected patients is a beneficial operation for the control of medically refractory parkinsonian resting and postural tremor. The effect of unilateral thalamotomy on tremor is long lasting.     

Comparison of thalamotomy to deep brain stimulation of the thalamus in essential tremor.

OBJECTIVE: To compare outcome in Essential Tremor (ET) patients who have undergone either thalamotomy or Deep Brain Stimulation (DBS) of the thalamus. BACKGROUND: Although both thalamotomy and thalamic DBS are effective surgical treatments of tremor, it is not known if one procedure is superior to the other. DESIGN/METHODS: Thirty-five ET patients underwent thalamotomy between 1994-1998. Data on 18 patients were excluded. The remaining 17 patients were matched for age, sex, side of surgery, and tremor severity to 17 ET patients who underwent thalamic DBS. There were nine men and eight women in each group. The mean age of the thalamotomy group was 74.4 years and that of the thalamic DBS group was 73.1 years. RESULTS: There were no significant differences between any efficacy outcome variables comparing thalamotomy to DBS of the thalamus at baseline or follow-up visits. The surgical complications were higher for the thalamotomy group as compared to the DBS group. However, a larger number of DBS patients underwent repeat surgeries due to problems with the device and the leads. CONCLUSION: Although the efficacy is similar for thalamotomy and DBS of the thalamus for ET, thalamotomy is associated with a higher complication rate. DBS of the thalamus should be the procedure of choice for the surgical treatment of ET in most cases.     

Clonidine in the treatment of essential tremor

The effect of clonidine treatment (average dose 0.4 mg/day) was investigated in 10 patients with essential tremor in a double-blind placebo-controlled design. Tremor amplitude and frequency were recorded with an accelerometer. Tremor was not significantly altered by clonidine therapy. Side effects were common. It is concluded that clonidine is not effective treatment for essential tremor.     

Disability in essential tremor: effect of treatment

We studied 18 patients with essential tremor for difficulty with handwriting, drinking, eating, fine manipulations, and embarrassment. Propranolol and primidone reduced the amplitude of both postural and kinetic tremor. Handwriting, drinking, and eating were improved with therapy, but fine manipulations and motor performance on tapping and pegboard tests were unaltered. Embarrassment remained unchanged. Essential tremor is not a benign condition; disability can be only partly reversed with drug therapy.     

Successful treatment of tremor in Wilson's disease by thalamotomy: A case report.

Little information is available on the surgical treatment of movement disorders in Wilson's disease. We report a successful outcome of left-sided stereotactic thalamotomy in a 30-year-old man with Wilson's disease, who had severe postural-kinetic tremor of both hands. The improvement was bilateral. Our case illustrates that stereotactic thalamotomy may be considered as an option in treating severe tremor in selected patients of Wilson's disease and merit further trials.     

Olanzapine efficacy in the treatment of essential tremor

We investigated the anti-tremor effect of olanzapine, a novel atypical antidopaminergic drug, in 37 patients with essential tremor (ET) in an open-label and prospective study by clinical scoring and patient self-evaluation. Olanzapine monotherapy appears to be efficacious for the treatment of ET. Further clinical trials with control groups are indicated to establish the efficacy of olanzapine in patients with ET.     

Assessing the impact of essential tremor on upper limb function

We compared the impact of essential tremor on the performance of three manual tasks: drawing spirals, holding a cup full of water and a joystick-controlled tracking test. Tremor amplitude and frequency were measured by accelerometry during the tracking test, when holding the cup and whilst a standard posture was maintained. The inter-relationships between tremor amplitude, frequency and task impairment were then examined. The results showed that the amplitude and frequency of essential tremor (measured from the principal spectral peak) changed with different activities, with the mildest postural tremors changing most in frequency (by up to 4–5 Hz). The amplitude of tremor decreased in almost every case during the tasks, relative to posture, and this decrement was greatest for the most severe tremors. We also demonstrate that for practical purposes, such as routine clinical situations and therapeutic trials, the effect of essential tremor upon upper limb function can be usefully assessed by two simple complementary techniques: rating spirals and measuring the volume of water split from a cup. The impairments in carrying out these tasks and the tracking test were highly correlated with one another and also with the amplitude and frequency of postural tremor. The concept of tremor suppressability is introduced: the relative percentage decrease in the amplitude of a particular tremor during the performance of a specific task compared to that recorded whilst holding a standard posture.     

Dose-response relationship of propranolol in the treatment of essential tremor

The effect of doses of propranolol hydrochloride, 80 to 800 mg/day, was investigated in 15 patients with essential tremor. The dose was increased by 80 mg weekly. Tremor was recorded by an accelerometer and its amplitude and frequency was determined by spectral analysis. Serum propranolol level was measured by radioreceptor assay. Tremor control varied greatly from complete suppression at 80 mg/day to no reduction at 800 mg/day. Mean serum propranolol levels increased with increasing dosage, but they did not correlate with tremor suppression. Five patients did not tolerate doses higher than 640 mg/day. Maximum tremor suppression occurred within a dose range between 160 and 320 mg/day. Higher doses did not cause additional tremor reduction.     

Increased tremor severity in bilineal essential tremor: a report of two families

Up to 6% of the general population have essential tremor (ET). In a number of couples both partners may have ET. The clinical profile of ET in children and the parents where both parents and the child have ET remains to be established. We report on two families where both parents and one child have ET. The severity of ET was greater in the children than in either parent. Such families could provide special opportunity to determine relation between genotype and phenotypic expression of ET.