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Abstract Details

Case Report: Jerky Dystonic Unsteady Hand Following High Frequency Focused Ultrasound Thalamotomy
Movement Disorders
P1 - Poster Session 1 (11:45 AM-12:45 PM)
5-020
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MRI-guided focused ultrasound (MRgFUS) thalamotomy, targeting the ventralis intermedius (Vim) nucleus, has emerged as an effective treatment for refractory tremors in essential tremor (ET). While it improves tremor symptoms significantly, it has been associated with adverse effects such as disturbances in strength, speech, swallowing, balance, and sensation. Rarely, it can lead to abnormal movements, such as dystonia, asterixis, and hemi-parkinsonism. This case highlights the emergence of post-procedural jerky dystonic unsteady hand previously reported with thalamic strokes/lesions. This has not been associated with MRgFUS thalamotomy so far.
An 82-year-old right-handed male with ET underwent MRgFUS targeting the left Vim to alleviate severe postural and kinetic tremors. He had been intolerant to first-line medications. The procedure was performed with the lesion on target, at standard coordinates, and of reasonable size, with no immediate complications. MRI performed immediately following MRgFUS demonstrated the expected left VIM ultrasound ablation. While his examination post-procedurally showed tremor improvement, he developed involuntary, insuppressible movements in his right hand on post-procedure day one. These abnormal hand movements were primarily jerky, choreiform, and exacerbated by voluntary activity, and asterixis in the proximal right arm muscles. No changes in speech or swallowing were observed. Although the patient had pre-existing sensory abnormalities due to neuropathy, these remained unchanged post-procedure. Delayed MRI imaging at 4 months postoperatively showed the same finding as above, without other explanatory findings. On the six months follow up, the abnormal movements did not change significantly, while the tremor continues to be suppressed.

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This case presents a rare instance of "jerky dystonic unsteady hand" following MRgFUS thalamotomy, resembling hyperkinetic movement disorders seen in thalamic infarction. It suggests that Vim lesioning may alter function in adjacent thalamic nuclei, contributing to hyperkinetic complications. Further research is needed to understand the underlying mechanisms.
Authors/Disclosures
Abdalmalik Bin Khunayfir, MD (Piedmont Healthcare)
PRESENTER 		Dr. Bin Khunayfir has nothing to disclose.
Stewart A. Factor, DO, FAAN (Emory University School of Medicine) Dr. Factor has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Neurocrine. Dr. Factor has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Factor has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Takeda. The institution of Dr. Factor has received research support from Biohaven. The institution of Dr. Factor has received research support from Neurocrine. The institution of Dr. Factor has received research support from Supernus. The institution of Dr. Factor has received research support from Sun Pharmaceuticals Advanced Research Company. The institution of Dr. Factor has received research support from Aspen. The institution of Dr. Factor has received research support from RHO. Dr. Factor has received publishing royalties from a publication relating to health care. Dr. Factor has received publishing royalties from a publication relating to health care. Dr. Factor has received publishing royalties from a publication relating to health care. Dr. Factor has received publishing royalties from a publication relating to health care.
Nicholas Au Yong (Emory University) An immediate family member of Nicholas Au Yong has received personal compensation for serving as an employee of Intuitive Surgical Inc.. An immediate family member of Nicholas Au Yong has received personal compensation for serving as an employee of Medtronic Inc.. An immediate family member of Nicholas Au Yong has stock in Intuitive Surgical Inc.. An immediate family member of Nicholas Au Yong has stock in Medtronic Inc.. The institution of Nicholas Au Yong has received research support from NIH. The institution of Nicholas Au Yong has received research support from Craig H. Neilsen Foundation. The institution of Nicholas Au Yong has received research support from Air Force Office of Scientific Research. Nicholas Au Yong has received intellectual property interests from a discovery or technology relating to health care. An immediate family member of Nicholas Au Yong has received intellectual property interests from a discovery or technology relating to health care.
Richa Tripathi, MD (Emory University) Dr. Tripathi has nothing to disclose.