MR-guided focused ultrasound thalamotomy in a patient with thrombocytopenia: illustrative case

Abstract

Background: MR-guided focused ultrasound (MRgFUS) thalamotomy is a relatively novel technique used to treat essential tremor (ET) and tremor-dominant Parkinson's disease. It is thought to be a safer alternative to other treatments, with no reported cases of major intracranial bleeding to date. However, experience with patients at increased risk of hemorrhage is still limited.

Observations: The authors present the case of a successfully treated ET patient with thrombocytopenia who experienced no postprocedural complications, detailing the surgical optimization strategy used. They conducted a systematic review of the literature, focusing on articles addressing MRgFUS in patients with known coagulation disorders. The Embase, Scopus, and MEDLINE databases were queried from their inception to August 20, 2024. Of the 973 screened abstracts, 2 relevant studies were identified. The first study included 40 patients undergoing MRgFUS without interruption of antiplatelet or anticoagulant therapy, while the second was a case report of a patient with von Willebrand disease. Both studies reported satisfactory safety profiles, with no increased incidence of hemorrhagic or other complications.

Lessons: Although evidence is limited due to the small number of studies and cases, these findings suggest that MRgFUS, with appropriate periprocedural optimization, represents a viable option for patients at heightened risk of intracranial hemorrhage. https://thejns.org/doi/10.3171/CASE2525.

Keywords: MR-guided focused ultrasound; coagulation disorder; functional neurosurgery; thalamotomy; thrombocytopenia.

FIG. 1.

Comparison of spiral drawings performed with the right hand before (left) and after (right) the procedure, demonstrating significant improvement in tremor severity.

FIG. 2.

Posttreatment axial (A) and coronal (B) 3D T1-weighted MR images demonstrating a hypointense lesion in the left thalamus showing associated restricted diffusion on the diffusion-weighted image (C). No hemorrhage is seen within the lesion on the blood-sensitive image (gradient echo) (D).

FIG. 3.

PRISMA flow diagram of the literature search of MRgFUS and coagulopathies. Data added to the PRISMA template (from Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71) under the terms of the Creative Commons Attribution (CC BY 4.0) License (https://creativecommons.org/licenses/by/4.0/).