Objective: To illustrate a successful stepwise dual target MRI guided focused ultrasound ablation in a patient with advanced Parkinson’s disease (PD).

Background: MR-guided focused ultrasound (MRgFUS) had been used for the treatment of PD. Currently, there is no single target that can ameliorate all cardinal Parkinson’s features. Recently, we published a novel method by conducting a stepwise dual-target focused ultrasound onto the pallid-thalamic tract (PTT) and thalamic Vim. Based on our findings, we illustrate the safety and efficacy of this method for managing advanced PD in a patient in this report.

Method: The 67-year-old man developed a left-limb rest tremor and slow motion 7 years ago. About 3 years later, he had right limb slowness. He responded well to levodopa and ropinirole. The beneficial period of medication was shortened to 2 hours in 2021. Freezing of gait during the off phase was developed in November 2022 with akathisia. Overt limb rigidity was detected, especially on the left, during off-state. Due to the significant wearing-off symptoms, MRgFUS was conducted for managing his problems. The PTT and Vim were navigated based on individual brain planning. The clinical rating scale of tremor, UPDRS III, non-motor score, and gait analysis were conducted.

Results: His left limb rest tremor disappeared after the PTT-focused ultrasound. The bradykinesia and rigidity were ameliorated by 70% after PTT ablation and up to 95% with Vim ablation. He felt a sudden relief in his left limbs from a long-term bounding during the peak energy-delivering status of the sonication. When assessed after the accomplishment of the procedure, we detected that the rigidity nearly disappeared, and he can even move his left limbs more fluently than his right. He can walk swiftly during off-state. In addition, his akathisia also vanished. One month later, his quality of life significantly improved, and he regained social activities. No side effects were reported.

Conclusion: We demonstrate that stepwise dual-target focused ultrasound benefits all the symptoms of PD. A single target can improve symptoms to a certain extent, but the second target maximizes the effect. Non-motor symptoms also improve. This safe treatment can be considered for advanced, asymmetric PD cases.

References: 1. Chen JC, Lu MK, Chen CM, Tsai CH. Stepwise Dual-Target Magnetic Resonance-Guided Focused Ultrasound in Tremor-Dominant Parkinson Disease: A Feasibility Study. World Neurosurg 2022.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/stepwise-dual-target-mr-guided-focused-ultrasound-in-a-patient-with-advanced-parkinsons-disease/