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Bilateral staged magnetic resonance-guided focused ultrasound thalamotomy for the treatment of essential tremor: a case series study
  1. Raúl Martínez-Fernández1,2,
  2. Sujitha Mahendran3,
  3. Jose Angel Pineda-Pardo1,2,
  4. Lukas L Imbach3,
  5. Jorge U Máñez-Miró1,
  6. Fabian Büchele3,
  7. Marta del Álamo1,
  8. Rafael Rodriguez-Rojas1,2,
  9. Frida Hernández-Fernández1,
  10. Beat Werner4,
  11. Michele Matarazzo1,2,
  12. Ignacio Obeso1,2,
  13. Lain H Gonzalez-Quarante1,5,
  14. Günther Deuschl3,6,
  15. Lennart Stieglitz7,
  16. Christian R Baumann3,
  17. Jose A Obeso1,2
  1. 1 HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
  2. 2 Centro de Investigacion Biomedica en Red sobre Enfermedades Neurodegenerativas, Madrid, Spain
  3. 3 Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
  4. 4 Center for Focused Ultrasound, Children’s Hospital Zurich, Zurich, Switzerland
  5. 5 Department of Neurosurgery, Clínica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
  6. 6 Department of Neurology, Universitätsklinikum Schleswig-Holstein Kiel, Campus Christian-Albrechts-University, Kiel, Germany
  7. 7 Department of Neurosurgery, University Hospital and University of Zurich, Zurich, Switzerland
  1. Correspondence to Prof Jose A Obeso, HM CINAC, Madrid 28938, Spain; jobeso.hmcinac{at}


Background Unilateral magnetic resonance-guided focused ultrasound (FUS) thalamotomy is efficacious for the treatment of medically refractory essential tremor (ET). Viability of bilateral FUS ablation is unexplored.

Methods Patients diagnosed with medically refractory ET and previously treated with unilateral FUS thalamotomy at least 5 months before underwent bilateral treatment. The timepoints were baseline (before first thalamotomy) and FUS1 and FUS2 (4 weeks before and 6 months after second thalamotomy, respectively). The primary endpoint was safety. Efficacy was assessed through the Clinical Rating Scale for Tremor (CRST), which includes subscales for tremor examination (part A), task performance (part B) and tremor-related disability (part C).

Results Nine patients were treated. No permanent adverse events were registered. Six patients presented mild gait instability and one dysarthria, all resolving within the first few weeks. Three patients reported perioral hypoesthesia, resolving in one case. Total CRST score improved by 71% from baseline to FUS2 (from 52.3±12 to 15.5±9.4, p<0.001), conveying a 67% reduction in bilateral upper limb A+B (from 32.3±7.8 to 10.8±7.3, p=0.001). Part C decreased by 81% (from 16.4±3.6 to 3.1±2.9, p<0.001). Reduction in head and voice tremor was 66% (from 1.2±0.44 to 0.4±0.54, p=0.01) and 45% (from 1.8±1.1 to 1±0.8, p=0.02), respectively.

Conclusion Bilateral staged FUS thalamotomy for ET is feasible and might be safe and effective. Voice and head tremor might also improve. A controlled study is warranted.

  • tremor
  • ultrasound

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  • RM-F and SM contributed equally.

  • CRB and JAO contributed equally.

  • Contributors RMF, SM, JAPP, CRB and JAO: conception, organisation and execution of the project, performance of FUS procedures, and writing of the first draft and revisions. LLI, JUMM, FB, RRR, MdA, FHF, MM, LHGQ, LS: execution of the project, performance of FUS procedures and review of manuscript. BW, IO: execution of the project and review of manuscript. GD: project conception and review of manuscript.

  • Funding This study was supported by the Fundación de Investigación HM Hospitales and InSightec, which provided funding for performance of ultrasound procedures.

  • Competing interests RMF has received honoraria for lecturing from InSightec. JAPP has received honoraria for lecturing and payment of travel expenses to attend scientific meetings from General Electric. JUMM receives grant support from InSightec. RMF, JAPP, JUMM, MdA, RRR and FHF have received honoraria for teaching in two courses sponsored by InSightec at HM Puerta del Sur (Mostoles, Madrid, Spain). JAO has received honoraria for lecturing and payment of travel expenses to attend scientific meetings from InSightec.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.