Wednesday, November 30, 2022
Wednesday, November 30, 2022
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Gamma Knife For Parkinson’s Disease

The Most Advanced Gamma Knife Technology

Gamma Knife Thalamotomy for Medically-Refractory Tremor in Patients not Suitable for DBS

At University Hospitals, we offer Perfexion technology, which is the most advanced Gamma Knife equipment available. It ensures the best possible results in the least amount of time for a wide range of patients. This state-of-the-art technology upgrade is expected to boost the number of patients that will benefit from Gamma Knife advanced technology by more than 40 percent.

How Does Gamma Knife Work

A multidisciplinary team of neurosurgeons, neuroradiologists, radiation oncologists, radiation physicists, and specialized nurses works closely together to ensure precise and effective treatment with the gamma knife.

First, the patient is fitted with a head frame, and the target within the brain is pinpointed using specialized imaging scans, such as magnetic resonance imaging or computed tomography . The frame is positioned in a special helmet so the radiation will be directed at the targeted area. The patient lies on a bed that slides into the gamma knife machine. Radiation is delivered through 201 ports inside the helmet, with the beams intersecting at the target.

The procedure takes 15 to 40 minutes and typically is performed with local anesthesia . During treatment, a video system and two-way intercom allow the patient and doctors to remain in contact.

Patients undergoing gamma knife treatment experience minimal, if any, discomfort and serious side effects are rare. Gamma knife treatment is usually performed on an outpatient basis.

Gamma Knife Radiosurgery For Parkinson’s Disease

1: Drummond PS, Pourfar MH, Hill TC, Mogilner AY, Kondziolka DS. SubthalamicGamma Knife Radiosurgery in Parkinson’s Disease: A Cautionary Tale. StereotactFunct Neurosurg. 2020 Feb 26:1-8. doi: 10.1159/000505709. PubMed PMID: 32101861.

2: Niranjan A, Raju SS, Lunsford LD. Leksell Radiosurgery for Movement Disorders.Prog Neurol Surg. 2019 34:279-288. doi: 10.1159/000493075. Epub 2019 May 16.Review. PubMed PMID: 31096233.

3: Israeli-Korn SD, Fay-Karmon T, Tessler S, Yahalom G, Benizri S, Strauss H,Zibly Z, Spiegelmann R, Hassin-Baer S. Decreasing battery life in subthalamicdeep brain stimulation for Parkinson’s disease with repeated replacements: Just amatter of energy delivered? Brain Stimul. 2019 Jul – Aug 12:845-850. doi:10.1016/j.brs.2019.02.008. Epub 2019 Feb 22. PubMed PMID: 30876884.

5: Sobstyl M, Konopka M, Aleksandrowicz M, Pasterski T, Zbek M. Successfulsubthalamic stimulation after failed gamma-knife thalamotomy in the treatment of tremor-dominant Parkinson’s disease. Neurol Neurochir Pol. 2019 53:169-171.doi: 10.5603/PJNNS.a2018.0007. Epub 2019 Jan 7. PubMed PMID: 30614519.

6: Altinel Y, Alkhalfan F, Qiao N, Velimirovic M. Outcomes in Lesion Surgeryversus Deep Brain Stimulation in Patients with Tremor: A Systematic Review andMeta-Analysis. World Neurosurg. 2019 Mar 123:443-452.e8. doi:10.1016/j.wneu.2018.11.175. Epub 2018 Nov 27. PubMed PMID: 30500587.

38: Sobstyl M, Zbek M. .Neurol Neurochir Pol. 2012 Jan-Feb 46:52-62. Review. Polish. PubMed PMID:22426763.

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Facts About Parkinson’s Disease

It is incorrectly believed that Parkinson’s disease disappeared after the introduction of levodopa in the 1960s. In fact, about 50,000 Americans are newly diagnosed with Parkinson’s disease each year, with more than half a million Americans affected at any one time. Further, more people suffer from Parkinson’s disease than multiple sclerosis, muscular dystrophy and amyotrophic lateral sclerosis combined.

Review Of Relevant Literature

A/Prof John W Fuller

GK thalamotomy is also an accepted treatment for tremors caused by PD. Duma, et al. created 42 radiosurgical thalamic lesions in 38 PD patients with GK thalamotomy and obtained promising results. The tremor was eliminated completely in 10 thalamotomies . Excellent improvement was seen in 11 , good improvement was seen in 13 , and mild improvement was seen in 4 . GK treatment did not affect 4 patient’s tremors. Therefore, 38 out of the 42 thalamotomies were deemed successful. However, one patient reportedly suffered a mild acute dysarthria one week after treatment.

Both RF thalamotomy and DBS have excellent reported control rates, but a varied side effect profile. Fox, et al. reported a 91% success rate and Jankovic, et al. reported a 90% success rate with open RF thalamotomy. Despite the high success rates, RF techniques put the patient at risk for intracerebral or extracerebral hemorrhage, seizures, infection, brain displacement, tension pnemocephalus, and direct injury from probe placement . Unemura, et al. performed a thorough review that evaluated the morbidity and mortality related to DBS. They noted 16 serious adverse events related to surgery in 14 of 109 patients. These included pulmonary embolism, subcortical hemorrhage, chronic SDH, venous infarction, seizure, infection, cerebrospinal fluid leak, skin erosion, and death.

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Gamma Knife Pallidotomy For Treatment Of Parkinsons Disease: Long Term Results Clinical Study

Ronald F. Young1, Francisco Li1, Sandra Vermeulen1, Daniel A. Clayton1, Robert D. Hesselgesser2

1 Los Robles Hospital and Medical Center , , USA

Correspondence to:

Background: Deep brain stimulation is now the preferred surgical treatment for advanced Parkinsons disease . Some patients however are not suitable candidates for an open surgical procedure or may prefer a procedure that does not include the permanent implantation of hardware. For such patients, gamma knife pallidotomy may be a suitable alternative.

Objective: The goal of this report was to describe the safety and effectiveness of posteroventral pallidotomy performed with the Leksell gamma knife for the treatment of advanced PD.

Methods: Forty patients underwent a total of 51 GKP procedures with LGK between August 1993 and June 2009. Twenty nine patients underwent a unilateral procedure whereas 11 underwent bilateral procedures.

Results: There were statistically significant improvements in off-medication unified Parkinsons disease rating scale scores for total scores , motor scores , tremor rigidity and bradykinesia scores and also for on medication dyskinesia scores Bilateral procedures produced an additional incremental improvement in symptoms. Two patients suffered permanent complications.

GKP offers a safe and effective procedure for the treatment of advanced PD. Although probably not as effective as DBS, it is particularly applicable to patients who may not be candidates for DBS.

What Is Gamma Knife

Not actually a “knife” at all, the gamma knife is a machine that emits hundreds of powerful, highly focused gamma radiation beams. The gamma knife allows for a more precise and concentrated treatment than do other radiation treatment options. This helps the doctors target the diseased area of the brain while sparing the healthy areas surrounding it.

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Gamma Knife With Radioneurosurgery In Parkinson

ABSTRACT

REFERENCES

  • Adler J.R., Colombo F., Heilbrun M.P., Winston K. Toward anExpanded View of Radiosurgery. Neurosurgery 2004 55:1374-6.

  • Pollock B.E., Lunsford L.D. A Call to Define StereotacticRadiosurgery. Neurosurgery 2004 55:1371-3.

  • Friehs GM, Noren G, Ohye C, Duma CM, Marks R, Plombon J,Young RF. Lesion size following gamma Knife Treatment for functional disorders. Stereotact Funct Neurosurg 1996 66:320-8.

  • Okun MS, Stover N, Subramanian T, Gearing M, Wainer B,Holder Ch, et al. Complications of Gamma Kinfe Surgery forParkinson Disease. Arch Neurol 2001 58:1995-2002.

  • Pan L, Dai JZ, Wang BJ, Xu WM, Zhou LF, Chen XR. StereotacticGamma Thalamotomy for the Treatment of Parkinsonism.Stereotact Funct Neurosurg 1996 66:329-32.

  • Duma CM, Jaques DB, Kopyov OV, Mark RJ, Copcutt B, FarokhiHK. Gamma knife radiosurgery for thalamotomy in parkinsoniantremor: a five-year experience. J Neurosurg 1998 88:1044-9.

  • Young RF, Vermeulen S, Posewitz A, Shumway-Cook A.Pallidotomy with the Gamma Knife: A Positive Experience.Stereotact Funct Neurosurg 1998 70:218-28.

  • Otsuki T, Jokura H, Takahashi K, Ishikawa S, Yoshimoto T, KimuraM, Yoshida R, Miyazawa T. Stereotactic ã-Thalamotomy with aComputerized Brain Atlas: Technical Case Report. Neurosurg1994 35:764-8.

  • Gabriel EM, Nashold BS: Evolution of Neuroablative Surgeryfor Involuntary Movement Disorders. An Historical Review.Neurosurgery 1998 42:575-91.

  • Guridi J, Lozano AM. A Brief History of Pallidotomy.Neurosurgery 1997 41:1169-83.

  • What Are The Four Primary Symptoms Of Parkinson’s

    Gamma Knife Treatment for Essential Tremor

    The following are the most common symptoms of Parkinson’s disease. However, each individual may experience symptoms differently. Symptoms may include:

    • Rigidity Stiffness when the arm, leg or neck is moved back and forth.
    • Resting Tremor Tremor most prominent at rest.
    • Bradykinesia Slowness in initiating movement.
    • Loss of Postural Reflexes Poor posture and balance that may cause falls gait or balance problems.

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    Box Inclusion And Exclusion Criteria

    Inclusion

    Manifest psychosis or personality disorder

    Selection CriteriaIf surgical intervention is to be performed with the patient awake, the patient must have the mental and physical stamina to endure a lengthy and demanding procedure and be cognitively healthy with low enough levels of anxiety to provide useful intraoperative feedback. Patients with dementia tend to become more confused intraoperatively, making them unable to provide reliable reports of adverse effects or fully participate in the procedure to determine clinical efficacy. Surgery may also worsen preexisting cognitive deficits.3-5 In general, with the exception of tremor, symptoms that do not improve with levodopa tend not to respond to surgery. Patient selection screening criteria for clinical and research evaluations of PD have been previously reported.6-8 Additional contraindications include severe uncontrolled hypertension, cancer, or cardiac, renal, hepatic, or pulmonary diseases .

    Complications Of Gamma Knife Surgery For Parkinson Disease

    Abstract & Commentary

    Okun MS, et al. Complications of gamma knife surgery for Parkinson disease. Arch Neurol. 2001 58:1995-2002.

    Neurosurgery in the past 50 years has developed several intracranial procedures involving the basal ganglia and thalamus in hopes to ameliorate the crippling factors of progressive, late-stage Parkinson disease . One relatively new, nonsurgical approach has consisted of using the noninvasive, radiosurgical gamma knife . The GK depends on first quality, cerebral MRIs to define by cubic millimeters the fine target structures that inhabit the particular patients thalamus and basal ganglia. From these mappings, the GK earlier directed an 8- or 4-mm collimater to control the radiation target size. A 4-mm diameter collimator has been designed to destroy just a 64 cu mm spot in the calculated thalamic or basal ganglia target. Two difficulties can occur from such steps, however. One can come immediately or the other can evolve from 1-12 months following the surgery. Unfortunately, Okun and colleagues encountered serious complications in 8 patients who underwent the GK. These all suffered distressing outcomes which appeared as follows: 1) body numbness, pseudobulbar, and laughter 2) hypophonia + aphasia 3) dysarthria, aspiration, and death 4) hand weak, dysarthria 5) hemiparesis 6) visual field loss 7) hemiparesis, dysarthria .

    Additional Reading

    1. Lang AE. Ann Neurol. 2000 47 :S193-S202.

    2. Friedman JH, et al. Ann Neurol. 1996 38:535-538.

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    Patient Factors In Determining Treatment

    During the natural history of ET, many patients may experience asymmetric symptoms with tremor more severely affecting or disabling one upper extremity. In these circumstances, patients may elect to undergo unilateral DBS surgery or a thalamotomy procedure to treat the affected upper extremity. Tremor in the contralateral side often progresses and may warrant additional surgical treatment. In these circumstances, DBS is the best option since several studies have reported unacceptably high rates of neurological deficits in speech, swallowing and cognition following bilateral thalamic lesioning procedures .

    Among patients with severe bilateral ET, DBS can be safely used bilaterally to treat tremor involving both upper extremities or with axial symptoms such as head or voice tremor. Many patients are satisfied with unilateral treatment of their dominant or more severely affected upper extremity, although many tasks require bimanual dexterity. Some surgeons advocate implanting bilateral thalamic DBS leads in a staged fashion to decrease the likelihood of complications. Although bilateral Vim DBS has been shown to improve overall tremor scores more than unilateral DBS or thalamotomy, it remains unclear whether bilateral treatment improves the overall quality of life in ET.

    Gamma Knife Relieves Uncontrollable Tremors In 84% Of Patients

    Gamma Knife Clinic

    Of the total, 116 people had tremors associated with Parkinson’s disease and 67 people had essential tremors. None of their tremors could be controlled with medication.

    An average of seven years after treatment, 84% of people had “significant or complete resolution” of tremors, Mark says.

    The findings were presented at the annual meeting of the American Society for Radiation Oncology.

    Mark says the results compare favorably with those obtained using the two other methods most commonly used to treat tremors that arenât helped by medication — deep brain stimulation, in which electrodes are surgically implanted in the brain, and radiofrequency ablation, which uses intense heat to burn tissue away.

    But the gamma knife appears to be safer, he says. Only three people, or 1.5%, experienced serious side effects, all in the form of brain swelling that can lead to partial paralysis. All three were treated successfully.

    In contrast, about 3% of people treated with deep brain stimulation experience brain bleeding and 5% of those treated with radiofrequency ablation develop serious infections, Mark says.

    “None of our patients had hemorrhage or infection. Many patients tell us they prefer the gamma knife because of the favorable results and the fact that there is no incision,” he says.

    But she cautions that patients need to make sure they are treated at medical centers whose doctors have experience with the technique.

    Show Sources

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    Other Symptoms Of Parkinson’s Disease

    Symptoms of Parkinson’s disease vary from patient to patient. The symptoms may appear slowly and in no particular order. Early symptoms may be subtle and may progress over many years before reaching a point where they interfere with normal daily activities.These often include the following:

    • Fatigue or general malaise

    Gamma Knife Radiosurgery Thalamotomy

    One of Leksells original aims in designing the Gamma Knife was for non-invasive treatment of functional and movement disorders. However, his original vision has been largely overshadowed by the successes of GK in neuro-oncology, trigeminal neuralgia and arteriovenous malformation treatment. So far, only GK has been used for thalamotomy among patients with ET, while linear accelerators have been used for thalamotomy in pain and parkinsonian tremor.

    During GK thalamotomy, patients are placed in a stereotactic frame under local anaesthetic. Typically, a single central maximal dose of 130152 Gy using a 4 mm collimator is administered to the Vim. Optimal planning minimises radiation exposure to the internal capsule.

    Most of the studies that we included were uncontrolled, retrospective and unblinded case series, which totalled approximately 350 unique patients from seven centres worldwide. These patients often had significant medical comorbidities necessitating anticoagulants , had refused DBS or previously underwent unsuccessful DBS or RF.

    Several authors suggest that staged bilateral SRS thalamotomy can be performed safely, although the documented experience is limited to only 51 patients with ET. No adverse events reported after the second SRS session. However, in non-ET SRS, serious adverse events, including coma and death from aspiration pneumonia, have been reported with bilateral SRS thalamotomy.

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    Comparison Of Gkp Rfp And Dbs

    GKP provides significant and durable improvements in motor performance in patients with PD. The magnitude of improvement is comparable to that which results from RFP Alkhani and Lozano published an excellent review of the RFP literature but Fine, et al. provided perhaps the best long-term study of the results of unilateral RFP in 20 of a cohort of 40 patients . They demonstrated a 37% short term and an 18% long term improvement in overall OFF-period UPDRS scores and as with our results and other prior reports for GKP, noted deterioration in these results over time . Likewise, they demonstrated an 18% long term improvement in OFF-period total motor scores. Both of these results are virtually identical to our results with GKP. In addition they demonstrated a 70% improvement in ON-period dyskinesia scores again very similar to our own results and like us they noted that these results did not deteriorate over time. It should also be noted that the Fine, et al. report includes only 20 of 40 RFP procedures performed at their institution and the authors indicate that the 20 excluded patients probably represent those with worse outcomes and thus the Fine, et al. report represents the best case scenario for the outcomes of RFP. In the present report only a single patient lost to follow up less than one year after the procedures were performed is excluded from the follow up data.

    What Is Parkinson’s Disease

    MIBS: Gamma Knife Radiosurgery for Parkinson Desease

    Parkinson’s disease is the most common form of parkinsonism, a group of motor system disorders.It is a slowly progressing, degenerative disease that is usually associated with the following symptoms, all of which result from the loss of dopamine-producing brain cells:

    • Tremor or trembling of the arms, jaw, legs and face
    • Stiffness or rigidity of the limbs and trunk
    • Postural instability, or impaired balance and coordination

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    Deep Brain Stimulation For Essential Tremor

    First reported in the late 1980s, DBS has become the most common surgical procedure for ET and was approved by the Food and Drug Administration in 1997. The intranuclear Vim/Vop ventrolateral thalamus is the traditional target for ablative procedures and neuromodulation in ET, which receives unconscious proprioceptive information from the cerebellar dentate nucleus via the dentatorubrothalamic tract . Within the Vim nucleus, cells that fire synchronously with the patients tremor can be electrically recorded, and disruption of this activity has long been known to arrest tremor.

    Since cerebellothalamic connections are thought to be important in tremor circuits, the PSA/cZI has been targeted for stimulation among patients with ET. Some investigators suggest that PSA/cZI DBS may have an advantage over Vim DBS in reducing side effects from stimulation. Although the number of PSA/cZI case series is smaller, it has been posited as an equally effective, but more efficient target, requiring less energy consumption from DBS systems.

    Case series have demonstrated a 62%95% reduction in overall tremor within the first year in unilateral PSA/cZI DBS and a 75.9%80.1% reduction in tremor in bilateral cases. Within the first 5 years after implantation, a similar reduction in efficacy has been demonstrated in unilateral and bilateral cases. Unilateral and bilateral PSA/cZI DBS have similar 1 year upper extremity tremor and ADL outcomes.

    Indications For Gamma Knife

    More than 350,000 Gamma Knife® procedures have been performed since the technology first became available in 1968. Almost a third of these patients sought relief from blood vessel problems . Nearly two-thirds were treated for brain tumors, including cancer, glial tumors and rarer types of tumors. A small percentage sought treatment to relieve functional disorders like unmanageable pain, trigeminal neuralgia, Parkinsons disease and epilepsy.

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