分阶段双侧聚焦超声丘脑切开术治疗本质性震颤的安全性和有效性:开放标签临床试验

IF 20.4 1区 医学 Q1 CLINICAL NEUROLOGY
Michael G Kaplitt, Vibhor Krishna, Howard M Eisenberg, W Jeffrey Elias, Pejman Ghanouni, Gordon H Baltuch, Ali Rezai, Casey H Halpern, Brian Dalm, Paul S Fishman, Vivek P Buch, Shayan Moosa, Harini Sarva, Ann Marie Murray
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引用次数: 0

摘要

重要性:在磁共振引导下对丘脑腹侧中间核进行单侧聚焦超声消融治疗可减轻一侧震颤,但未经治疗的对侧或中线症状仍会限制部分患者的病情。过去,双侧病变会带来不可接受的风险,因此被脑深部刺激所取代;越来越多的人接受单侧聚焦超声病变治疗,这引起了人们对双侧病变治疗的兴趣:评估分阶段、双侧聚焦超声丘脑切开术的安全性和有效性:这项前瞻性、开放标签、多中心试验于 2020 年 7 月至 2021 年 10 月在美国 7 家学术医疗中心对本质性震颤患者进行治疗,随访 12 个月。62 名入选患者在入选前至少 9 个月接受了单侧聚焦超声丘脑切开术,其中 11 人被排除在外,51 人接受了治疗。入选标准包括患者年龄(22 岁及以上)、药物难治性、震颤严重程度(震颤临床分级量表 [CRST] A 部分评分≥2(姿势性或运动性震颤))和功能障碍(CRST C 部分评分≥2(任何类别)):聚焦超声系统与磁共振成像连接,可将热成像图与解剖结构实时对齐。阈下超声可在进行消融前检查目标的疗效和脱靶效应:主要结果和测量指标:治疗后 3 个月,治疗侧的震颤/运动评分(CRST A 和 B 部分)是主要结果测量指标,疗效和安全性的次要评估持续到 12 个月:平均(标清)年龄为 73(13.9)岁,44 名参与者(86.3%)为男性。3个月时,震颤/运动评分的平均值(标清)从17.4(5.4;95% CI,15.9-18.9)提高到6.4(5.3;95% CI,4.9-7.9)(CRST A部分和B部分评分提高66%;95% CI,59.8-72.2;P 结论及意义:分阶段进行的双侧聚焦超声丘脑切开术显著降低了震颤的严重程度和功能障碍评分。语言、吞咽和共济失调方面的不良反应大多是轻微和短暂的:试验注册:ClinicalTrials.gov Identifier NCT04112381。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Safety and Efficacy of Staged, Bilateral Focused Ultrasound Thalamotomy in Essential Tremor: An Open-Label Clinical Trial.

Importance: Unilateral magnetic resonance-guided focused ultrasound ablation of ventralis intermedius nucleus of the thalamus for essential tremor reduces tremor on 1 side, but untreated contralateral or midline symptoms remain limiting for some patients. Historically, bilateral lesioning produced unacceptable risks and was supplanted by deep brain stimulation; increasing acceptance of unilateral focused ultrasound lesioning has led to interest in a bilateral option.

Objective: To evaluate the safety and efficacy of staged, bilateral focused ultrasound thalamotomy.

Design, setting, and participants: This prospective, open-label, multicenter trial treated patients with essential tremor from July 2020 to October 2021, with a 12-month follow-up, at 7 US academic medical centers. Of 62 enrolled patients who had undergone unilateral focused ultrasound thalamotomy at least 9 months prior to enrollment, 11 were excluded and 51 were treated. Eligibility criteria included patient age (22 years and older), medication refractory, tremor severity (Clinical Rating Scale for Tremor [CRST] part A score ≥2 for postural or kinetic tremor), and functional disability (CRST part C score ≥2 in any category).

Intervention: A focused ultrasound system interfaced with magnetic resonance imaging allowed real-time alignment of thermography maps with anatomy. Subthreshold sonications allowed target interrogation for efficacy and off-target effects before creating an ablation.

Main outcomes and measures: Tremor/motor score (CRST parts A and B) at 3 months for the treated side after treatment was the primary outcome measure, and secondary assessments for efficacy and safety continued to 12 months.

Results: The mean (SD) population age was 73 (13.9) years, and 44 participants (86.3%) were male. The mean (SD) tremor/motor score improved from 17.4 (5.4; 95% CI, 15.9-18.9) to 6.4 (5.3; 95% CI, 4.9 to 7.9) at 3 months (66% improvement in CRST parts A and B scores; 95% CI, 59.8-72.2; P < .001). There was significant improvement in mean (SD) postural tremor (from 2.5 [0.8]; 95% CI, 2.3 to 2.7 to 0.6 [0.9]; 95% CI, 0.3 to 0.8; P < .001) and mean (SD) disability score (from 10.3 [4.7]; 95% CI, 9.0-11.6 to 2.2 [2.8]; 95% CI, 1.4-2.9; P < .001). Twelve participants developed mild (study-defined) ataxia, which persisted in 6 participants at 12 months. Adverse events (159 of 188 [85%] mild, 25 of 188 [13%] moderate, and 1 severe urinary tract infection) reported most commonly included numbness/tingling (n = 17 total; n = 8 at 12 months), dysarthria (n = 15 total; n = 7 at 12 months), ataxia (n = 12 total; n = 6 at 12 months), unsteadiness/imbalance (n = 10 total; n = 0 at 12 months), and taste disturbance (n = 7 total; n = 3 at 12 months). Speech difficulty, including phonation, articulation, and dysphagia, were generally mild (rated as not clinically significant, no participants with worsening in all 3 measures) and transient.

Conclusions and relevance: Staged, bilateral focused ultrasound thalamotomy significantly reduced tremor severity and functional disability scores. Adverse events for speech, swallowing, and ataxia were mostly mild and transient.

Trial registration: ClinicalTrials.gov Identifier NCT04112381.

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来源期刊
JAMA neurology
JAMA neurology CLINICAL NEUROLOGY-
CiteScore
41.90
自引率
1.70%
发文量
250
期刊介绍: JAMA Neurology is an international peer-reviewed journal for physicians caring for people with neurologic disorders and those interested in the structure and function of the normal and diseased nervous system. The Archives of Neurology & Psychiatry began publication in 1919 and, in 1959, became 2 separate journals: Archives of Neurology and Archives of General Psychiatry. In 2013, their names changed to JAMA Neurology and JAMA Psychiatry, respectively. JAMA Neurology is a member of the JAMA Network, a consortium of peer-reviewed, general medical and specialty publications.
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