Ilana Erikh

MRI Guided Focused Ultrasound Thalamotomy for Moderate-to-Severe Tremor in Parkinson’s Disease

Background. Thalamotomy is effective in alleviating tremor in Parkinsons disease (PD). Methods. Seven PD patients, mean age 59.4 ± 9.8 years (range, 46–74) with a mean disease duration of 5.4 ± 2.8 years (range, 2–10) suffering from severe refractory tremor, underwent ventral intermediate nucleus thalamotomy using MRI guided focused ultrasound (MRgFUS), an innovative technology that enables noninvasive surgery. Results. Tremor stopped in the contralateral upper extremity in all patients immediately following treatment. Total UPDRS decreased from 37.4 ± 12.2 to 18.8 ± 11.1 (p = 0.007) and PDQ-39 decreased from 42.3 ± 16.4 to 21.6 ± 10.8 (p = 0.008) following MRgFUS. These effects were sustained (mean follow-up 7.3 months). Adverse events during MRgFUS included headache (n = 3), dizziness (n = 2), vertigo (n = 4), and lip paresthesia (n = 1) and following MRgFUS were hypogeusia (n = 1), unsteady feeling when walking (n = 1, resolved), and disturbance when walking tandem (n = 1, resolved). Conclusions. Thalamotomy using MRgFUS is safe and effective in PD patients. Large randomized studies are needed to assess prolonged efficacy and safety.

Asymmetric pain processing in Parkinson's disease

Reduced endogenous pain inhibition, as part of the degenerative process, is presumed to be the mechanism underlying the common presence of pain in patients with Parkinsons disease (PD). The present study aimed to assess an endogenous pain inhibitory system in PD using the conditioned pain modulation paradigm.

Parkinson's disease tremor is diminished with relaxation guided imagery.

Patients with Parkinsons disease (PD) may have pronounced tremor that exacerbates during stress. To determine whether PD tremor improves with relaxation guided imagery (RGI) and relaxing music. Twenty patients with PD with moderate to severe tremor participated in sessions where relaxation techniques were implemented. Tremor was objectively monitored using an accelerometer. RGI dramatically decreased tremor in all 20 patients (baseline 270.38 ± 85.82 vs. RGI 35.57 ± 43.90 movements per minute P < 0.0001). In 15 patients, RGI completely abolished tremor for 1–13 min. Average tremor activity remained significantly bellow baseline both 15 min and 30 min after RGI was discontinued (P < 0.001). Patients reported improvement lasting 2–14 hours (mean 6.8 ± 3.8). Relaxing music significantly reduced tremor but to a lesser degree than RGI (220.04 ± 106.53 movements per minute P = 0.01). Self‐relaxation had no significant effect on tremor. RGI can supplement conventional medical treatments for tremor in patients with PD on best medical treatment.

Paradoxical kinesia at war

Paradoxical kinesia is the sudden transient ability of a patient with Parkinsons disease to perform a task he was previously unable to perform, usually when facing an immediate threat. The sensory cues governing this behavior and the prevalence in real life situations are unknown. The objective of this study was to determine the occurrence of paradoxical kinesia in Parkinsons disease (PD) patients whose residential area was suddenly a war zone, under a life threatening missile attack, necessitating immediate evacuation. Fifty PD patients were interviewed during and immediately following the war. Only two patients experienced paradoxical kinesia, one war related and the other historical, both in response to visual cues. In contrast, an auditory stimulus in the form of a frightening loud siren, warning patients of an imminent missile attack, did not induce paradoxical kinesia. When questioned about their general function during wartime, patients reported significant increases in OFF time (P < 0.01), dyskinesia (P < 0.009), anxiety (P < 0.002), and depression (P < 0.01) as compared with their performance before the war. Paradoxical kinesia is uncommon, even in the face of danger. Visual, but not auditory, triggers appear to be needed to prompt its occurrence.

Restless legs syndrome in stroke patients

BACKGROUND Restless legs syndrome (RLS) is associated with cerebrovascular risk factors, but its possible association with cerebrovascular disease has yielded conflicting results. OBJECTIVE This was a case-control, in-hospital study to evaluate the association between RLS and acute stroke or transient ischemic attack (TIA). METHODS We evaluated patients hospitalized with acute stroke/TIA and an age and gender 2:1 frequency-matched control group, for the presence of RLS. RESULTS Twenty-two of 149 patients (15%) and 10 of 298 controls (3%) suffered from RLS (p <0.0001). A multivariate logistic regression model employing cerebrovascular risk factors as predictors, that is, hypertension, hyperlipidemia, diabetes, and body mass index (BMI), determined that stroke/TIA was significantly associated with RLS with odds ratio for RLS among patients with stroke/TIA versus controls of 7.60 (95% confidence interval (CI): 2.07-27.87; p = 0.002). Another multivariate logistic regression model adjusting for possible RLS risk factors, that is, hypertension, hyperlipidemia, diabetes, BMI, anemia, and reduced renal function, determined that stroke/TIA was significantly associated with RLS with odds ratio of 6.85 (95% CI: 6.85-1.79; p = 0.005). Stepwise logistic regression with hypertension, hyperlipidemia, diabetes, BMI, anemia, and reduced renal function as potential predictors revealed that only stroke/TIA predicted RLS with similar odds ratio to the RLS-based multivariate model of 6.54 (95% CI: 2.63-16.27; p <0.0001). CONCLUSIONS Examining stroke patients while in hospital allowed us to conclude that RLS and acute stroke/TIA are significantly associated. However, the cross-sectional design did not allow for the determination of a causative relationship between the two.

MR guided focused ultrasound as a treatment tool for essential and Parkinsonian tremor

Combining focused ultrasound (FUS) with real time MRI guidance and monitoring enables a new non-invasive treatment of brain disorders. In this technique multisource ultrasound waves are focused at a single point raising the temperature gradually until ablation occurs. Lesions as small as 2-4 mm can be made, without impact on surrounding tissue or remote brain tissue. Our aim was to assess MR guided focused ultrasound (MRgFUS) as a new non-invasive surgical tool for treating essential and parkinsonian tremor by thalamotomy of the ventral-intermediate nucleus.