Magnetic resonance-guided focused ultrasound ventral intermediate thalamotomy for Tremor-Dominant Parkinson's disease: a systematic review and meta-analysis.

INTRODUCTION: Tremor-dominant Parkinson's Disease (TDPD) has a slower neurological decline compared to other phenotypes of the disease, but significantly impacts daily activities and is often less responsive to standard medications. Magnetic Resonance-guided Focused Ultrasound (MRgFUS) lesioning of the Ventral Intermediate (VIM) nucleus of the thalamus may alleviate symptoms for these patients. METHODS: A systematic review and meta-analysis of English-language studies from PubMed, Cochrane, and Embase were conducted, assessing the efficacy and safety of MRgFUS VIM thalamotomy in TDPD patients. Tremor scores were evaluated using the Clinical Scale Rating for Tremor and the Movement Disorders Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRSIII). Neuropsychological outcomes were measured using the Parkinson Disease Questionnaire (PDQ) and the Montreal Cognitive Assessment. This analysis adhered to Cochrane and PRISMA guidelines. RESULTS: Thirteen studies with 211 patients were included. MDS-UPDRSIII scores showed significant improvement at 1, 6, and 12 months post-MRgFUS, respectively: (MD -8.92 points, 95% CI: -15.44 to -2.40, p < 0.01; MD -7.39 points, 95% CI: -11.47 to -3.30, p < 0.01; MD -10.66 points, 95% CI: -16.89 to -4.43, p < 0.01). PDQ scores at baseline compared to 6 months post-treatment also indicated a significant improvement (SMD - 0.86, 95% CI: -1.21 to -0.50, p < 0.01). Neurological adverse events were generally mild and transient, with gait instability and sensory deficits being the most common. CONCLUSION: This meta-analysis demonstrates significant improvements in tremor and neuropsychological outcomes following MRgFUS VIM thalamotomy in TDPD patients, with adverse events being typically mild and transient.

Deep brain stimulation of the subthalamic nucleus under general anesthesia versus local anesthesia in the treatment of Parkinson's disease: a meta-analysis of randomized clinical trials.

Deep brain stimulation (DBS) stands as the preferred treatment for Parkinson's disease (PD) patients manifesting refractory motor symptoms or when medication side effects outweigh the benefits. Though traditionally administered under local anesthesia coupled with sedation (LA + S), recent evidence hints at comparable outcomes under general anesthesia (GA). This systematic review and meta-analysis aimed to scrutinize post-surgical outcomes in randomized PD patients undergoing DBS surgery while GA versus LA + S. We searched PubMed, Cochrane, and Embase databases following PRISMA guidelines. We included randomized studies directly comparing DBS surgery under GA versus LA + S, delineating clinical outcomes. Safety outcomes assessed disparities in infection and hemorrhage risk. Mean differences (MD) and Risk Differences (RD) with 95% Confidence Intervals (CI) were utilized to evaluate outcomes, under a random-effects model. Heterogeneity was evaluated through I² statistics, and in studies exhibiting high heterogeneity, exclusion analysis was performed. Evaluated outcomes encompassed motor improvement, complications, behavioral and mood effects gauged by the Unified Parkinson's Disease Rating Scale (UPDRS), Parkinson's Disease Questionnaire 39 (PDQ39), and daily levodopa equivalent dose (LEDD). A total of 3 studies, encompassing 203 patients, were reviewed. At a 6-month follow-up, in patients undergoing GA during surgery, there was no statistically significant difference compared to the LA + S group in terms of UPDRS III ON (MD 0.19; 95% CI -2.21 to 2.59; p = 0.88; I²=0%), UPDRS III OFF (MD 0.58; 95% CI -4.30 to 5.45; p = 0.21; I²=0%), UPDRS IV ON ( (MD 0.98; 95% CI -0.95 to 2.92; p = 0.32; I²=23%), PDQ39 (MD -1.27; 95% CI -6.31 to 3.77; p = 0.62; I²=0%), and LEDD (MD -1.99; 95% CI -77.88 to 73.90; p = 0.96; I²=32%). There was no statistically significant difference between groups in terms of infection (RD 0.02; 95% CI -0.02 to 0.05; p = 0.377; I²=0%) or hemorrhage (RD 0.04; 95% CI -0.03 to 0.11; p = 0.215; I²=0%). Our findings suggest, based on short-term follow-up, that GA is not inferior to LA + S in terms of benefits for the selected outcomes. However, further studies are needed to determine whether there are significant long-term clinical differences between these groups.