Objective: The purpose of this study was to retrospectively analyze the outcomes of stereotactic radiosurgery for patients suffering from medically refractory Parkinson disease (PD) tremor. Methods: We retrospectively studied the outcomes of 33 patients who were treated with gamma knife thalamotomy (GKT) over a 19-year period. Twelve patients were ≥80 years. A median dose of 140 Gy (range, 130-150 Gy) was delivered to the nucleus ventralis intermedius through a single 4-mm isocenter. We used the Fahn-Tolosa-Marin clinical tremor rating scale to score tremor, handwriting, drawing, and ability to drink fluids. The median time to the last follow-up was 23 months (range, 9-144 months). Results: After GKT, 31 patients (93.9%) experienced improvement in tremor. Twenty-three patients (70.0%) had complete or nearly complete tremor arrest. Nine patients (27.2%) noted tremor arrest and resolution of impairment in writing, drawing, and ability to drink fluids. One patient (3%) improved in bradykinesia, 3 patients (9%) improved in rigidity, and 3 patients (9%) decreased their dosage of dopa after GKT. Tremor relief was fully maintained in the last follow-up for 96.8% of responding patients. Two patients (6%) experienced temporary adverse radiation effects. Conclusions: GKT is a safe and effective treatment for medically refractory PD tremor, especially for the elderly or those not suitable for deep brain stimulation or thermal thalamotomy.

1.
Willis AW: Parkinson disease in the elderly adult. Mo Med 2013;110:406-410.
2.
Fahn S, Tolosa E, Marin C: Clinical rating scale for tremor; in Jankovic J, Tolosa E (eds): Parkinson's Disease and Movement Disorders. Baltimore, Williams & Wilkins, 1993, pp 271-280.
3.
Alvarez L, Macias R, Pavon N, Lopez G, Rodriguez-Oroz MC, Rodriguez R, Alvarez M, Pedroso I, Teijeiro J, Fernandez R, Casabona E, Salazar S, Maragoto C, Carballo M, Garcia I, Guridi J, Juncos JL, DeLong MR, Obeso JA: Therapeutic efficacy of unilateral subthalamotomy in Parkinson's disease: results in 89 patients followed for up to 36 months. J Neurol Neurosurg Psychiatry 2009;80:979-985.
4.
Starr PA, Vitek JL, Bakay RA: Ablative surgery and deep brain stimulation for Parkinson's disease. Neurosurgery 1998;43:989-1013; discussion 1013-1015.
5.
Benabid AL, Benazzouz A, Hoffmann D, Limousin P, Krack P, Pollak P: Long-term electrical inhibition of deep brain targets in movement disorders. Mov Disord 1998;13(suppl 3): 119-125.
6.
Benabid AL, Pollak P, Gao D, Hoffmann D, Limousin P, Gay E, Payen I, Benazzouz A: Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg 1996;84:203-214.
7.
Bronstein JM, Tagliati M, Alterman RL, Lozano AM, Volkmann J, Stefani A, Horak FB, Okun MS, Foote KD, Krack P, Pahwa R, Henderson JM, Hariz MI, Bakay RA, Rezai A, Marks WJ Jr, Moro E, Vitek JL, Weaver FM, Gross RE, DeLong MR: Deep brain stimulation for Parkinson disease: an expert consensus and review of key issues. Arch Neurol 2011;68:165.
8.
Deuschl G, Paschen S, Witt K: Clinical outcome of deep brain stimulation for Parkinson's disease. Handb Clin Neurol 2013;116:107-128.
9.
Hariz MI, Shamsgovara P, Johansson F, Hariz G, Fodstad H: Tolerance and tremor rebound following long-term chronic thalamic stimulation for parkinsonian and essential tremor. Stereotact Funct Neurosurg 1999;72:208-218.
10.
Kumar R, Lozano AM, Sime E, Lang AE: Long-term follow-up of thalamic deep brain stimulation for essential and parkinsonian tremor. Neurology 2003;61:1601-1604.
11.
Pahwa R, Lyons KE, Wilkinson SB, Simpson RK Jr, Ondo WG, Tarsy D, Norregaard T, Hubble JP, Smith DA, Hauser RA, Jankovic J: Long-term evaluation of deep brain stimulation of the thalamus. J Neurosurg 2006;104:506-512.
12.
Pakarian P, Rayegani SM, Shahzadi S: Effect of Vim thalamic DBS in Parkinson's disease on F wave duration. Neurosci Lett 2004;367:323-326.
13.
Volkmann J: Deep brain stimulation for the treatment of Parkinson's disease. J Clin Neurophysiol 2004;21:6-17.
14.
Yamamoto T, Katayama Y, Kano T, Kobayashi K, Oshima H, Fukaya C: Deep brain stimulation for the treatment of parkinsonian, essential, and poststroke tremor: a suitable stimulation method and changes in effective stimulation intensity. J Neurosurg 2004;101:201-209.
15.
Gregory R: Surgery for movement disorders. J Neurol Neurosurg Psychiatry 2002;72(suppl 1):I32-I35.
16.
Kleiner-Fisman G, Herzog J, Fisman DN, Tamma F, Lyons KE, Pahwa R, Lang AE, Deuschl G: Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord 2006;21(suppl 14): S290-S304.
17.
Campbell AM, Glover J, Chiang VL, Gerrard J, Yu JB: Gamma knife stereotactic radiosurgical thalamotomy for intractable tremor: a systematic review of the literature. Radiother Oncol 2015;114:296-301.
18.
Duma CM, Jacques D, Kopyov OV: The treatment of movement disorders using Gamma Knife stereotactic radiosurgery. Neurosurg Clin North Am 1999;10:379-389.
19.
Friedman DP, Goldman HW, Flanders AE, Gollomp SM, Curran WJ Jr: Stereotactic radiosurgical pallidotomy and thalamotomy with the gamma knife: MR imaging findings with clinical correlation - preliminary experience. Radiology 1999;212:143-150.
20.
Kooshkabadi A, Lunsford LD, Tonetti D, Flickinger JC, Kondziolka D: Gamma Knife thalamotomy for tremor in the magnetic resonance imaging era. J Neurosurg 2013;118:713-718.
21.
Lim SY, Hodaie M, Fallis M, Poon YY, Mazzella F, Moro E: Gamma knife thalamotomy for disabling tremor: a blinded evaluation. Arch Neurol 2010;67:584-588.
22.
Ohye C, Higuchi Y, Shibazaki T, Hashimoto T, Koyama T, Hirai T, Matsuda S, Serizawa T, Hori T, Hayashi M, Ochiai T, Samura H, Yamashiro K: Gamma knife thalamotomy for Parkinson disease and essential tremor: a prospective multicenter study. Neurosurgery 2012;70:526-535; discussion 535-536.
23.
Pan L, Dai JZ, Wang BJ, Xu WM, Zhou LF, Chen XR: Stereotactic gamma thalamotomy for the treatment of parkinsonism. Stereotact Funct Neurosurg 1996;66(suppl 1):329-332.
24.
Young RF, Jacques S, Mark R, Kopyov O, Copcutt B, Posewitz A, Li F: Gamma knife thalamotomy for treatment of tremor: long-term results. J Neurosurg 2000;93(suppl 3): 128-135.
25.
Witjas T, Carron R, Krack P, Eusebio A, Vaugoyeau M, Hariz M, Azulay JP, Regis J: A prospective single-blind study of Gamma Knife thalamotomy for tremor. Neurology 2015;85:1562-1568.
26.
Elias WJ, Lipsman N, Ondo WG, Ghanouni P, Kim YG, Lee W, Schwartz M, Hynynen K, Lozano AM, Shah BB, Huss D, Dallapiazza RF, Gwinn R, Witt J, Ro S, Eisenberg HM, Fishman PS, Gandhi D, Halpern CH, Chuang R, Butts Pauly K, Tierney TS, Hayes MT, Cosgrove GR, Yamaguchi T, Abe K, Taira T, Chang JW: A randomized trial of focused ultrasound thalamotomy for essential tremor. N Engl J Med 2016;375:730-739.
27.
Magara A, Buhler R, Moser D, Kowalski M, Pourtehrani P, Jeanmonod D: First experience with MR-guided focused ultrasound in the treatment of Parkinson's disease. J Ther Ultrasound 2014;2:11.
28.
Bond AE, Dallapiazza R, Huss D, Warren AL, Sperling S, Gwinn R, Shah BB, Elias WJ: A randomized, sham-controlled trial of transcranial magnetic resonance-guided focused ultrasound thalamotomy trial for the treatment of tremor-dominant, idiopathic Parkinson disease. Neurosurgery 2016;63(suppl 1): 154.
29.
Schlesinger I, Eran A, Sinai A, Erikh I, Nassar M, Goldsher D, Zaaroor M: MRI guided focused ultrasound thalamotomy for moderate-to-severe tremor in Parkinson's disease. Parkinsons Dis 2015;2015:219149.
30.
InSightec: A Feasibility Study to Evaluate Safety and Initial Effectiveness of ExAblate Transcranial MR Guided Focused Ultrasound for Unilateral Thalamotomy in the Treatment of Medication-Refractory Tremor Dominant Idiopathic Parkinson's Disease. Bethesda, ClinicalTrials.gov, 2016.
31.
InSightec: A Feasibility Clinical Trial of the Management of the Medically Refractory Dyskinesia Symptoms of Advanced Idiopathic Parkinson's Disease with Unilateral Lesioning of the Globus Pallidum Using the ExAblate Transcranial System. Besthesda, ClinicalTrials.gov, 2016.
32.
InSightec: A Feasibility Clinical Trial of the Management of the Medically Refractory Motor Symptoms of Advanced Parkinson's Disease with Staged, Unilateral Lesioning of the Subthalamic Nucleus Using the ExAblate Transcranial System. Besthesda, ClinicalTrials.gov, 2016.
33.
InSightec: Feasibility Trial Evaluating the Safety and Efficacy of ExAblate Transcranial Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Unilateral Pallidotomy for the Treatment of L-Dopa Induced Dyskinesia (LID) of Parkinson's Disease. Besthesda, ClinicalTrials.gov, 2016.
34.
InSightec: A Feasibility Study to Evaluate Safety and Initial Effectiveness of ExAblate Transcranial MR Guided Focused Ultrasound for Unilateral Pallidotomy in the Treatment of Dyskinesia of Parkinson's Disease. Bethesda, ClinicalTrials.gov, 2016.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.