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INTRODUCTION: MR-guided high intensity focused ultrasound (MRgFUS) is a novel, noninvasive technique for the treatment of functional brain disorders through the intact human skull at millimeter precision. The ExAblate 4000 transcranial MRgFUS system (InSightec, Haifa, Israel) uses a 1024-element phased array transducer, which is attached to the patient’s head via a standard stereotactic frame situated inside a 3T MRI scanner. It is CE certified for neurological interventions in the thalamus, hypothalamus and pallidum.

CASE REPORT: Recently MRgFUS was successfully used as an alternative method to standard DBS for the treatment of therapy-resistant rest tremor of the arm and the hand in a high risk patient (m,44), with tremor-dominant idiopathic Parkinson’s disease, who
showed contraindication to DBS due to a history of i.v. drug abuse, HIV infection, hepatitis C and lung disease.

METHODS: During interventions the target was visually focused by MR-image guidance. In a first step, the correct focal location was verified with low, non-ablative energy, and targeted in the pallido-thalamic tract (fasciculus thalamicus) of the subthalamic area, contralateral to the dominant resting tremor. Continuous sonications lasting 15 to 25 seconds each were delivered with stepwise increased acoustic energy up to 13200 J to create thermocoagulations under realtime MR-thermometry. The sonications resulted in heating to 60°C at the focal point producing a thermal lesion. Circulating de-gassed water between the helmet shaped transducer and the patient’s head provided acoustic coupling and head cooling. After each sonication the patient was interviewed and neurologically tested. The size of the lesion was closely monitored by MR-imaging during and immediately after treatment, and again after 48 hours and at one month.

RESULTS: Clinically, MRgFUS intervention resulted in a prompt and
complete suppression of the tremor, both at rest and under provocation, which remains to date. No adverse effects were noted.

CONCLUSION: MRgFUS is a novel technique for the treatment of neurological disorders that is noninvasive and does not use ionizing or radioactive radiation. The technique has been proven successful worldwide for neuropathic pain and essential tremor treatment in over 70 treated patients so far. First experience with MRgFUS suggests it to be a safe and potentially effective alternative to standard DBS implantation for the treatment of tremor-dominant Parkinson’s disease.