Name:
10.3171/2024.7.FOCVID2462
Description:
10.3171/2024.7.FOCVID2462
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/b4b82c3a-1392-4a80-9a6b-d00fd577e9b2/videoscrubberimages/Scrubber_324.jpg
Duration:
T00H06M47S
Embed URL:
https://stream.cadmore.media/player/b4b82c3a-1392-4a80-9a6b-d00fd577e9b2
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/b4b82c3a-1392-4a80-9a6b-d00fd577e9b2/5. 24-62.mp4?sv=2019-02-02&sr=c&sig=py5N1SJ5bIIu2%2B%2F4UbpLmgRyPu44YuQ332MSMBOFA%2FI%3D&st=2026-04-26T12%3A54%3A43Z&se=2026-04-26T14%3A59%3A43Z&sp=r
Upload Date:
2026-04-26T12:59:43.4668713Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we demonstrate stereotactic radiofrequency lesioning of caudal zona incerta for parkinsonian tremor. A 70-year-old gentleman presented with Parkinson's disease, primarily expressing left-sided upper-limb tremors that significantly impeded his daily activities. The severity of tremors, assessed using the UPDRS-III scoring for both rest and kinetic movements, was deemed moderate. Additionally, he exhibited mild tremors in other body parts, along with mild rigidity and bradykinesia.
SPEAKER: Despite therapeutic attempts with levodopa, and carbidopa, trihexyphenidyl, and propranolol, the tremors proved resistant. Following a comprehensive discussion regarding the potential benefits and constraints of lesioning procedure, he consented to undergo stereotactic right-sided caudal zona incerta radiofrequency thermocoagulation. Herein, we can see the tremors at rest and during work.
SPEAKER: A preoperative magnetic resonance imaging with thin sections and proton density fat saturation was conducted for improved visualization of the red and subthalamic nuclei. Administered under local anesthesia, the stereotactic frame was meticulously aligned parallel to the orbitomeatal line, after which a thin-section computed tomography scan was performed.
SPEAKER: Both the MRI and CT scans were merged utilizing the inbuilt software. The anterior commissure and posterior commissure were marked on MRI, and the imaging was reset according to the AC-PC line. The red nucleus and subthalamic nucleus are marked with green dotted lines. The delineation of the caudal zona incerta was accomplished through direct visualization. At the section displaying the maximum dimensions of the red nucleus, three lines were demarcated: the first traversing the midpoint of the red nucleus, the second intersecting the lateral boundary of the red nucleus, and the third tangent to the medial edge of the subthalamic nucleus.
SPEAKER: On the line connecting the lateral border of the red nucleus and the medial border of subthalamic nucleus, a point was marked at the 2/3, 1/3 junction. The intended target within the CZi is precisely situated at this marked point. The entry point is marked at or interior to the coronal suture, approximately 2.5 to 3 centimeters off the midline. Care is taken to avoid ventricles, sulci, and vessels.
SPEAKER: If the trajectory involves the subthalamic nucleus, then the trajectory is medialized. In most cases, the trajectory of CZi and ventralis intermediate nucleus, that is VIM, can coincide with the CZi target just inferior to the VIM. The coordinates for the frame were noted. Thereafter, the patient was brought into the operating room, where the stereotactic arc was accurately positioned according to the predetermined coordinates.
SPEAKER: Following the planned approach, a burr hole was meticulously created at the designated entry point. Subsequently, a 2-millimeter- diameter radiofrequency electrode, featuring an exposed tip measuring 2 millimeters in length, was carefully inserted until reaching the target. The length of the electrode, set at 185 millimeters, adhered to the center of arc principle applicable to the utilized frame. During the procedure, the patient underwent intraoperative high-frequency stimulation at 100-Hertz frequency, 1- millisecond pulse width, and 1.3 to 1.7 volts to assess the motor response.
SPEAKER: Additionally, low-frequency stimulation was employed at 2-Hertz frequency, 1-millisecond pulse width, and 1.3 to 3.5 volts to establish the motor threshold. Remarkably, the patient experienced immediate relief from tremors upon high-frequency stimulation. Subsequently, two temporary lesioning phases were conducted: the first at 45 degrees Celsius for 30 seconds and second at 55 degrees Celsius for another 30 seconds, aimed at evaluating potential adverse effects such as paresis or speed changes.
SPEAKER: After a thorough assessment, the final lesioning procedure was performed at 75 degrees Celsius for 60 seconds. The postoperative CT scan delineates the location of the lesion. Herein, we can compare the resolution of tremors both in rest and in kinetic conditions.
SPEAKER: The effect persisted in the follow-up. There is class I evidence supporting the efficacy of deep brain stimulation in the caudal zona incerta for tremors. In contrast to VIM, which targets only the cerebellothalamic pathway, the CZi targets both the hyperdirect and cerebellothalamic pathway. The hyperdirect pathway plays a pivotal role in the therapeutic application of deep brain stimulation of the subthalamic nucleus for Parkinson's disease.
SPEAKER: Moreover, CZi has demonstrated safety from a cognitive perspective in treating essential tremors. A comprehensive pooled analysis indicated the superiority of the posterior subthalamic area, that is CZi, over VIM in addressing essential tremors. While there is evidence for radiofrequency lesioning of CZi for posttraumatic tremor, herein we have illustrated its role in the case of parkinsonian tremor.
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