NEUROSURGICAL

  FOCUS Neurosurg Focus 44 (2):E9, 2018

EDITORIAL
Tremor, thalamotomy, and cognition
Ying Meng, MD, and Nir Lipsman, MD, PhD

Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Ontario, Canada

E
ssential tremor (ET) is the most common move- have the additional advantage of shorter recovery times,
ment disorder and, contrary to widespread belief, is lower infection rates, and no need for long-term program-
not an exclusively monosymptomatic motor-circuit ming and battery replacement. Compared with those of
condition. Neurocognitive studies of patients with ET stereotactic radiosurgery, the bioeffects of ultrasound are
have consistently shown a decrease in multiple domains nonionizing and immediate, allowing the surgeon to ad-
of executive function, such as spatial processing, working just the targeting in real time. While medically refractory
memory, and language.5,8 The pathophysiology of this is ET is the procedure’s first clinically approved indication
complex and could be linked to contributions from dys- in the central nervous system, high-intensity MRgFUS
function in the fronto-thalamic-cerebellar loops as part is also being investigated for tremor-dominant Parkinson
of a cerebellar cognitive affective syndrome (CCAS).5 As disease, chronic pain, obsessive-compulsive disorder, and
a result, surgical interventions within the thalamus, espe- major depressive disorder, among others.
cially on the dominant side, can put already vulnerable While the clinical effects of MRgFUS on tremor and
patients at risk for further cognitive deterioration. resultant QOL have been characterized, the influence of
Surgical strategies in patients with refractory mo- the procedure on neurocognitive symptoms is unknown—
tor symptoms, including ET, are rapidly evolving. To the and important to determine. Jung et al. report tremor, neu-
currently available options, namely radiofrequency thala- rocognitive, and QOL assessment in 20 patients with ET
motomy and deep brain stimulation (DBS), we can now who underwent left-sided MRgFUS thalamotomy.6 The
add less invasive procedures, such as Gamma Knife radio- Seoul Neuropsychological Screening Battery (SNSB),
surgery and MR-guided focused ultrasound (MRgFUS). commonly used in Korea for dementia and other neuro-
Common to all of these is intervention within the ventral logical disorders, was applied to test domains of attention,
intermediate nucleus (Vim) of the thalamus, an operation language, visuospatial function, verbal memory, and fron-
leading to significant improvement in tremor and quality tal executive function.1 A blinded assessor administered
of life (QOL), but one whose side-effect profile can in- the test at baseline and 6 months after treatment. Quality
clude neurocognitive and other effects.7 In the context of of life was measured via the Quality of Life in Essential
an emerging surgical strategy, it is critical to study not Tremor Questionnaire (QUEST). Jung and colleagues’
only its putative benefits but also, and perhaps more im- most important finding was that scores on all domains
portantly, its potential pitfalls. In their paper, Jung et al. of the SNSB did not significantly decline after treatment,
report on the first study to specifically address neurocog- with statistically significant improvements in certain as-
nitive changes after MRgFUS thalamotomy for medically pects, such as the Korean version of the Boston Naming
refractory ET.6 Test and memory functions.
In high-intensity MRgFUS, ultrasound penetrates the These results are certainly interesting and raise im-
skull from multiple sources to converge on a discrete in- portant points about measuring and following more than
tracranial target, raising tissue temperature and generating just motor scores in ET patients postoperatively. Common
a thermocoagulative lesion. The advantages of MRgFUS adverse events following MRgFUS procedures can be di-
are real-time image guidance and the ability to raise tem- vided into those that occur during the procedure (nausea
peratures to sublesional levels to assess for adverse events or dizziness) and those that occur postoperatively (pares-
prior to generating a permanent lesion. These operations thesia and gait disturbances). Sensory disturbances can

ACCOMPANYING ARTICLE  DOI: 10.3171/2017.11.FOCUS17625.

©AANS 2018, except where prohibited by US copyright law Neurosurg Focus  Volume 44 • February 2018 1

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result from encroachment on the sensory relay posterior to cognitive impairments in dementia patients. J Korean Med
the Vim, whereas gait and weakness occur with laterally Sci 25:1071–1076, 2010
placed lesions. Although the majority of these events are   2. Alomar S, King NKK, Tam J, Bari AA, Hamani C, Lozano
AM: Speech and language adverse effects after thalamotomy
transient, some are not and can have significant impacts and deep brain stimulation in patients with movement disor-
on functioning, notwithstanding the impact on tremor. ders: a meta-analysis. Mov Disord Off J Mov Disord Soc
Neuropsychological effects are even less well character- 32:53–63, 2017
ized. Speech disturbances, reported as dysarthria, are   3. Elias WJ, Lipsman N, Ondo WG, Ghanouni P, Kim YG, Lee
documented at an incidence from 0% to 7% in several W, et al: A randomized trial of focused ultrasound thalamot-
MRgFUS ET studies.3,4,9 By comparison, a meta-analysis omy for essential tremor. N Engl J Med 375:730–739, 2016
of radiofrequency thalamotomy and thalamic DBS for ET   4. Huss DS, Dallapiazza RF, Shah BB, Harrison MB, Diamond
showed respective rates of approximately 4.5% and 10.3% J, Elias WJ: Functional assessment and quality of life in es-
sential tremor with bilateral or unilateral DBS and focused
verbal problems after unilateral treatment.2 Importantly, ultrasound thalamotomy. Mov Disord Off J Mov Disord
with DBS, side effects can be improved or controlled with Soc 30:1937–1943, 2015
adjustments to stimulation parameters.   5. Janicki SC, Cosentino S, Louis ED: The cognitive side of
Given Jung et al.’s results and the procedure’s putative essential tremor: what are the therapeutic implications? Ther
advantages in visualizing lesion size and tissue tempera- Adv Neurol Disord 6:353–368, 2013
ture, it is tempting to think that MRgFUS thalamotomy   6. Jung NY, Park CK, Chang WS, Jung HH, Chang JW: Effects
is somehow unique in having a neurocognitive benefit for on cognition and quality of life with unilateral magnetic
resonance–guided focused ultrasound thalamotomy for esen-
patients; however, the authors concede that the noted im- tial tremor. Neurosurg Focus 44(2):E8, 2018
provements could be attributable to learning effects on re-   7. Schuurman PR, Bruins J, Merkus MP, Bosch DA, Speelman
test and that the relatively small sample size renders broad JD: A comparison of neuropsychological effects of thala-
conclusions difficult. Nevertheless, we applaud the authors motomy and thalamic stimulation. Neurology 59:1232–1239,
for addressing a critical, and as yet unanswered, question 2002
in the MRgFUS and surgical ET literature. Indeed, with   8. Sinoff G, Badarny S: Mild cognitive impairment, dementia,
the growing number of technologies available to treat ET, and affective disorders in essential tremor: a prospective
study. Tremor Other Hyperkinet Mov (N Y) 4:227, 2014
now and in the future, the side-effect profile of these inter-   9. Zaaroor M, Sinai A, Goldsher D, Eran A, Nassar M,
ventions will be as, if not more, important as tremor im- Schlesinger I: Magnetic resonance–guided focused ultra-
provement in determining which procedure patients and sound thalamotomy for tremor: a report of 30 Parkinson’s
their surgeons will choose. disease and essential tremor cases. J Neurosurg 128:202–
https://thejns.org/doi/abs/10.3171/2017.11.FOCUS17682 210, 2018

References
  1. Ahn HJ, Chin J, Park A, Lee BH, Suh MK, Seo SW, et al:
Seoul Neuropsychological Screening Battery-Dementia Ver- Disclosures
sion (SNSB-D): a useful tool for assessing and monitoring The authors report no conflict of interest.

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