CORRESPONDENCE these modalities, potentially finding specific subgroups of patients In Reply: Thalamotomy-Like Eec ff ts from in which one therapy is more effective than the other. Until then, Partial Removal of a Ventral Intermediate DBS remains the preferred treatment modality for patients with Nucleus Deep Brain Stimulator Lead in a bilateral symptoms and without other medical comorbidities. Patient With Essential Tremor To the Editor: Disclosures We appreciate the thoughtful analysis by Maugeri et al of Research activities of Dr Lim are supported by grants from the California Institute for Regenerative Medicine (CIRM RT2-01975), the Department of our article, “Thalamotomy-Like Effects from Partial Removal of Veterans Affairs (1I01 BX000252-04), the Shurl and Kay Curci Foundation, and a Ventral Intermediate Nucleus Deep Brain Stimulator Lead in 2 the Sontag Foundation. Dr Lim is a consultant to Accurexa, Inc. a Patient With Essential Tremor.” In our report, a patient who was not receiving benefit from ventral intermediate (Vim) nucleus John D. Rolston, MD, PhD deep brain stimulation (DBS) was scheduled for a revision of the ∗ ‡ Daniel A. Lim, MD, PhD electrode to the zona incerta. However, adhesions at the tip of Department of Neurological Surgery the electrode led to a mechanical lesion in the thalamus during University of California, San Francisco attempted removal. Postoperatively, the patient experienced a Surgical Service benefit greater than that achieved by DBS, even though the lesion San Francisco Veterans Affairs Medical Center was in the same tissue as the electrode’s tip. Though this is only San Francisco, California a single case, our observations imply that lesioning and DBS can have different effects on the same anatomical target. Maugeri et al note in their letter that lesioning has garnered REFERENCES renewed interest following innovations in focused ultrasound 1. Magueri R, Franzini A, Giugno A, Iacopino DG. Letter: thalamotomy-like 3,4 (FUS). The minimally invasive nature of FUS makes it an effects from partial removal of a ventral intermediate nucleus deep brain stimu- attractive alternative to radiofrequency ablation, though compli- lator lead in a patient with essential tremor: case report. Neurosurgery. 2017;80(4): E254-E255. cations may still occur from thermal damage to tissue adjacent to 2. Rolston JD, Ramos AD, Heath S, Englot DJ, Lim DA. Thalamotomy-like effects the intended target. In any case, in patients with failed DBS, like from partial removal of a ventral intermediate nucleus deep brain stimulator lead in the case we presented, FUS loses some of its advantages. Specif- a patient with essential tremor: case report. Neurosurgery. 2015;77(5):E831-E836; discussion E836-E837. ically, FUS would require removal of the ineffective electrode 3. Iacopino DG, Giugno A, Maugeri R, et al. Is there still a role for lesioning in before proceeding, requiring an invasive surgical procedure that functional neurosurgery: the Italian experience of delivering focused ultrasound high would obviate some of the procedure’s potential advantages. energy through a 1,5 tesla MR apparatus. J Neurosurg Sci. 2015. Revision of the electrode to alternative sites, such as the zona 4. Weintraub D, Elias WJ. The emerging role of transcranial magnetic resonance 5,6 imaging–guided focused ultrasound in functional neurosurgery. Mov Disord. incerta, or placing a radiofrequency lesion with the already 2017;32(1):20-27. implanted DBS lead, are viable alternatives in situations of failed 5. Blomstedt P, Sandvik U, Linder J, Fredricks A, Forsgren L, Hariz MI. Deep brain Vim therapy. stimulation of the subthalamic nucleus versus the zona incerta in the treatment of essential tremor. Acta Neurochir. 2011;153(12):2329-2335. On the other hand, if there truly is a differential therapeutic 6. Plaha P, Khan S, Gill SS. Bilateral stimulation of the caudal zona incerta nucleus effect of lesioning compared to DBS, there may be a subgroup of fortremorcontrol. J Neurol Neurosurg Psychiatr. 2008;79(5):504-513. patients who would experience greater benefit from an upfront 7. Strickland BA, Jimenez-Shahed J, Jankovic J, Viswanathan A. Radiofrequency lesion than DBS, and vice versa. Unfortunately, we currently do lesioning through deep brain stimulation electrodes: a pilot study of lesion geometry and temperature characteristics. J Clin Neurosci. 2013;20(12):1709-1712. not have methods for making this clinical distinction, if it exists. As investigations of FUS continue, it will be important to carefully compare patient-level outcomes to those from conventional DBS, with an eye toward identifying possible differences in therapeutic 10.1093/neuros/nyx068 effects. Doing so would permit more targeted trials to compare E256 | VOLUME 80 | NUMBER 5 | MAY 2017 www.neurosurgery-online.com
Neurosurgery – Oxford University Press
Published: May 1, 2017
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