Surgery for Tremor
MRI-guided focused ultrasound
New in Russia
procedure for patients
with tremor, movement disorders and dystonias
What does it mean to live with trembling hands?
Drink from a glass or insert a key into a lock, write a text message, make a call, get dressed, brush your teeth, sign a document… Such everyday activities become difficult or even impossible for patients with essential tremor because their hands, legs, or head shake.
Tremor is the involuntary shaking of one or more parts of the body. There are a number of diseases that cause this movement disorder, such as Parkinson’s disease.
Another condition accompanied by shaking is essential tremor. It most often affects the hands, less frequently the legs, head, or voice. Essential tremor is a common condition, occurring in 0.3 to 22% of people depending on the region and its inhabitants. In about 25% of cases, tremor leads to a change of job, early retirement, or disability.
How to help people with essential tremor?
But the diagnosis of “Essential Tremor” is not a sentence. Such people can be helped.
Patients with essential tremor often experience severe psychological stress, and in severe forms of the disease, even the simplest daily activities may become impossible, significantly reducing quality of life. It is sad to see how society, by labeling a person with shaking hands, makes life even more difficult for someone with tremor. The exact causes of this disease are still unclear; research indicates that the trigger may be dysfunction in certain nerve cells in brain areas such as the thalamus. Now my childhood dream has come true, where helping people with trembling hands is possible without incisions, by targeting the responsible areas of the thalamus
Neurosurgeon at the V.S. Buzaev International Medical Centre®, Rezida Maratovna Galimova.
MRI-guided focused ultrasound helps eliminate essential tremor, dystonia, and neuropathic pain.
Methods of Treating Patients with Essential Tremor, Movement Disorders, and Dystonias
Until the last decade, various medications and deep brain stimulation surgery were used as standard treatments for essential tremor ( DBS), gamma knife treatment and radiofrequency thalamotomy
Conservative treatment Tremor is often not adequately controlled with medication. Drug therapy can be associated with side effects such as dizziness and, quite often, may not help.
Deep Brain Stimulation ( DBS). Deep brain stimulation is a neurosurgical procedure in which electrodes are implanted into the nuclei or pathways of deep brain structures and stimulated with alternating electrical current. This allows for a significant reduction in tremor. The advantage of the method is that it can treat both sides of the body simultaneously, but like any invasive surgery, deep brain stimulation carries risks such as infections or brain hemorrhage, and the stimulator needs to be replaced every few years.
Thalamotomy with Gamma Knife Thalamotomy with a gamma knife allows targeting ionizing radiation beams at the area suspected of causing tremor and irradiating it. The main disadvantage of the method is that the target area is determined by anatomical landmarks. Deviation of target nuclei positions from typical anatomy occurs in up to 40% of cases. If the irradiation is aimed at an innocent area, the effect becomes unpredictable. Complications may increase over several months due to the gradual death of brain cells in the irradiated zone. Cases of death after such treatment have even been described in the literature.
Radiofrequency ablation Radiofrequency ablation is a neurosurgical procedure in which electrodes are inserted into the brain under anesthesia. The patient is then awakened, tests are conducted to find the area responsible for the tremor, and it is cauterized using radiofrequency exposure, similar to a microwave. The main drawback of the procedure is brain damage during electrode insertion.
Treatment with MRI-guided focused ultrasound At the V.S. Buzaev International Medical Centre (Russia), an innovative method for treating tremor and involuntary movements of the hands, legs, and head using MRI-guided focused ultrasound (MRgFUS) has been introduced for the first time in Russia.
Comparison of Treatment Methods for Trembling Hands Presented in the table at the end of this page
MRgFUS MRgFUS, Neuravive treatment, MRI-guided focused ultrasound. What is this magical method for treating tremor?
With MRI-guided focused ultrasound, patients with essential tremor can be treated effectively and gently. A new method for treating essential tremor and tremor-dominant Parkinson’s syndrome has been developed by the company Insightec and is labeled CE, that is, approved in Europe, approved FDA in the USA, and now approved by Roszdravnadzor and available in Russia. To date, approximately 5000 patients worldwide have been successfully treated with its help.
First, the safety and effectiveness of treating tremor with MRI-guided focused ultrasound are related to the fact that there is no need to open the skull and penetrate the brain with instruments.
Secondly, one of the incredible advantages of this method is that it allows the precise targeting of brain areas suspected of causing hand tremor with an accuracy of 0.1 mm using ultrasound. Ultrasound has a remarkable property; it can “stun” brain cells for 2-3 minutes. This allows the doctor to simulate and check what will happen if this specific area of the brain is turned off in a particular person. This helps avoid impairing brain functions, such as numbness or speech disorders, in the treatment of tremor. The doctor can determine whether targeting this specific area will help in combating hand tremor.
MRI-guided focused ultrasound. Technology on the verge of a miracle
A helmet with a thousand ultrasound emitters is placed on the patient’s head. These ultrasound sources can be controlled individually. The ultrasound waves, like an optical magnifying glass, are focused on a millimeter-sized area of the brain.
At the target point, the energy delivered by the ultrasound heats the tissue. At low intensities, this temporarily stuns brain cells and allows for verification of targeting accuracy. At high energies, the ultrasound effect permanently disables the nerve cells responsible for tremor.
During treatment, the patient is awake and does not require anesthesia. Doctors communicate with the patient and assess their sensations and neurological state. In most cases, tremor improves immediately after treatment, but on one side. The V.S. Buzaev International Medical Centre (Russia) is one of the most innovative medical centers in Europe. Currently, such operating rooms are not available in many European countries.
New Surgery. A film by Igor Buzaev about a new surgical method.
Indications for the use of MRgFUS in the treatment of patients with essential tremor*
- Age over 22 years
- Confirmed diagnosis of essential tremor and refractoriness to drug therapy (propranolol or primidone)
- Absence of contraindications for performing a CT scan of the skull before therapy to determine bone density
- No contraindications for MRI.
- No pathological changes in the projection of the thalamus and subthalamic nucleus on brain MRI
- The patient’s ability to undergo a therapy session without sedation or with minimal sedation.
- The patient’s ability to understand and perform motor tests during the procedure and activate the button to stop sonication Stop Sonication).
* — Therapy of Movement Disorders Using the Focused MRI-guideded focused ultrasound Recommendations for Neurologists on Patient Selection .
R.M. Galimova, S.N. Illarioshkin, I.V. Buzaev, O.V. Kachemaeva
How to get treatment for hand tremors?
The attending physician, if modern and well-read, should inform patients with essential tremor about the treatment possibilities using MRgFUS and can refer them to our center. We also support the presence of the attending physician and the patient’s relatives during the procedure.
After a patient contacts us from anywhere in Russia or the world, we conduct an online consultation. During this, we determine whether treatment with focused ultrasound is suitable or if there are contraindications for our patient.
Are there any disadvantages of MRgFUS?
During any treatment, patients must be informed about the effectiveness and possible risks. On our YouTube videos posted on the channel with examples before and after treatment
First, there is a small chance that the tremor may return months or even years after treatment or may not improve at all. According to the literature, among patients with essential tremor, such cases are less than 5%.
Secondly, there is a slight risk of temporary or permanent muscle weakness, instability, loss of sensation, numbness, or tingling in the fingers or other parts of the body.
Thirdly, although the treatment can reduce tremor, it is important to understand that this procedure, like any other surgical methods, does not cure the underlying disease, nor does it prevent the deterioration or progression of the disease.
During the procedure, short periods of 10-20 seconds of ultrasound activation are conducted. At this moment, patients usually do not feel anything, but some may experience nausea, pain, or other sensations. These sensations disappear after the ultrasound is turned off.
MRI-guided focused ultrasound treatment — the latest non-invasive method to assist patients
with extrapyramidal movement disorders in Parkinson’s disease, patients with essential tremor, cervical dystonias are now available to residents of Russia and nearby countries
Table. Pros and Cons of Different Surgeries for Essential Tremor
| Conservative | DBS | RFA | gamma knife | MRgFUS | |
| Efficiency | <90% | >90% | >90% | <90% | >90% |
| Incisions and Holes in the Skull | No | there is | there is | No | No |
| Damage to areas not involved in tremor by radiation | No | No | No | Yes | No |
| Introduction of instruments through brain structures | No | there is | there is | No | No |
| Foreign bodies implanted in the brain | No | there is | No | no | No |
| The need for a repeat surgery to replace a depleted stimulator | No | there is | No | No | No |
| Possibility of Trial Target Determination Before Treatment | after inserting the electrode into the brain | after inserting the electrode into the brain | No | there is a possibility without incisions and instruments | |
| Risk of hemorrhage | No | there is | there is | extremely low | extremely low |
| Risk of suppuration | No | there is | there is | No | theoretically possible at the point of contact between the helmet and the skin, but no cases have been described in the literature |
| Anesthesia | no anesthesia | Awakening from Anesthesia During Surgery for Functional Tests | Awakening from Anesthesia During Surgery for Functional Tests | no anesthesia | no anesthesia |
| Average time in hospital | 7 days | 7 days | less than a day | less than a day | |
| In the intensive care unit after surgery | maybe | maybe | extremely low probability | extremely low probability | |
| Possibility of Bilateral Treatment | possibly simultaneously | avoid due to possible loss of speech | No | possibly in stages, there are simultaneous publications |
Read more
Essential Tremor. All About the Condition.