Bilateral Focused Ultrasound Pallidotomy for Parkinson-Related Facial Dyskinesia-A Case Report.
Authors: Stieglitz LH, Mahendran S, Oertel MF, Baumann CR
For safety reasons, both magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) thalamotomy and pallidotomy are currently approved exclusively for unilateral treatment, but axial symptoms like levodopa-induced orofacial dyskinesia require a bilateral approach. We report the first case of successful bilateral MRgHiFUS pallidotomy for peak-dose dyskinesia in a patient with Parkinson's disease (PD). The treatment decision was based on the patient's reluctance toward brain implants and pump therapies and the fact that he had limited access to a deep brain stimulation center in his home country. The treatment was planned as staged procedure with an interval of 18 months because of travel restrictions because of the coronavirus disease (COVID)-19 pandemic. After the second treatment, levodopa-induced orofacial dyskinesia remitted and improved bradykinesia and rigidity with stable gait and good postural reflexes. This promising result suggests that in selected PD patients with dyskinesia, staged bilateral MRgHiFUS pallidotomy might be considered.
Introduction
Purpose
Thermal ablation
Study Objective
To report the first successful case of staged bilateral MRgHiFUS pallidotomy to treat levodopa‑induced peak‑dose orofacial dyskinesia in a patient with Parkinson's disease.
Animal model / Human subject
Homo sapiens; strain: N/A; 77 years; male
Disease model
Parkinson's disease (levodopa-induced peak-dose/orofacial dyskinesia)
MRI or image guidance method
Magnetic resonance-guided (MRgHiFUS)
Targeted brain region(s)
Globus Pallidus Internus (Gpi)
Target coordinates
Left Gpi: ML 20.1 mm, AP 9.2 mm posterior, DV 3.7 mm inferior; Right Gpi: ML 20.0 mm, AP 9.5 mm posterior, DV 3.5 mm inferior
Route of administration
oral
Outcomes and Safety
Summary of Outcomes
Staged bilateral MRgHiFUS pallidotomy completely resolved levodopa‑induced orofacial dyskinesia and improved bradykinesia and rigidity with stable gait and no ablation‑related side effects at 2.5‑month follow‑up. Successful sonication parameters reported were: left GPi—three therapeutic sonications up to 26,500 J and 59°C; right GPi—three therapeutic sonications (after two aborted attempts) up to 20,000 J and 58°C.
Duration of biological effect
2.5 months
Safety-related matter
Peri‑ and post‑procedural monitoring revealed no new neurological deficits or pallidotomy‑related side effects and no cognitive or psychiatric decline, with only a mild intra‑procedural headache reported; the patient later developed a deep venous thrombosis during a flight after missing anticoagulant doses (unrelated to the procedure). The authors note prior reports of adverse events after bilateral pallidotomies (choreoathetoid dyskinesia, speech deterioration, increased salivation, gait freezing, handwriting problems) and state that safety and long‑term effects require further prospective study.
Brain Region
Ultrasound Parameters
Ultrasound instrument
MRgHiFUS
FUS Mode
continuous
Focal Characteristics
Focal depth: None; Focal length: None; Aperture size: None
Treatment frequency
Multiple sessions
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