AAN 2026 | The evolution of functional neurosurgery for movement disorders
Alfonso Fasano, MD, PhD, FAAN, University of Toronto, Toronto, Canada, discusses the evolution of functional neurosurgery for movement disorders, from lesioning the brain using radiofrequency to the development of deep brain stimulation (DBS) and more recently, MRI-guided focused ultrasound. Dr Fasano highlights the potential of focused ultrasound for treating various movement disorders, including essential tremor and Parkinson’s disease. This interview took place at the 78th American Academy of Neurology (AAN) Annual Meeting in Chicago, IL.
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Transcript
Functional neurosurgery for movement disorders is a long tradition and indeed started with lesioning the brain. Back in the days, neurosurgeons used to do lesions using radiofrequency, then DBS came and for most part, this type of technique was abandoned, even though there’s still a role for their use. And in more recent years, there’s been an interest in using less invasive ways to perform lesions in the brain; gamma knife was developed a while back and there have been some studies using it for movement disorders, but for sure when you ask me about what’s new in this space, I need to mention MRI-guided focused ultrasound, which is the newest way to perform lesions in the brain without opening the skull, the skin...
Functional neurosurgery for movement disorders is a long tradition and indeed started with lesioning the brain. Back in the days, neurosurgeons used to do lesions using radiofrequency, then DBS came and for most part, this type of technique was abandoned, even though there’s still a role for their use. And in more recent years, there’s been an interest in using less invasive ways to perform lesions in the brain; gamma knife was developed a while back and there have been some studies using it for movement disorders, but for sure when you ask me about what’s new in this space, I need to mention MRI-guided focused ultrasound, which is the newest way to perform lesions in the brain without opening the skull, the skin. So we call it incisionless, meaning that it’s still a brain operation. It’s still a procedure done to the brain to create indeed a lesion in the brain, but there is no opening. And therefore, patient acceptance is much higher than what we see with other techniques where we need to go through the skin and the skull and the brain to obtain the effect we were obtaining for movement disorders. So focused ultrasound is being directed towards classical targets of functional neurosurgery like the VIM in the thalamus to treat tremor, that’s approved by the FDA and other agencies for essential tremor, with also the possibility of doing a staged bilateral procedure, so meaning that after six, nine months, the patient can receive the same treatment on the other side of the brain. Then other targets approved for this condition are the pallidum, unilateral pallidotomy for Parkinson’s disease, and more recently, the PTT. PTT stands for pallidothalamic tract. It’s a bundle of fibers in the white matter between the thalamus and the posterior area behind the subthalamus. And a lesion in this part of the brain mimics the same effect of a lesion in the pallidum to some extent. And that’s also approved for staged bilateral, again, for Parkinson’s disease. Also for Parkinson’s disease, there is thalamotomy. Again, VIM approved for tremor related to Parkinson’s disease. Also for Parkinson’s disease, there is a thalamotomy, again VIM approved for tremor related to Parkinson’s disease, although my prediction is that now the PTT lesioning is approved, most people with Parkinson’s, even with tremor only coming from Parkinson’s, will receive PTT lesioning, unilateral staged bilateral, like I said. So this is an interesting avenue because it’s bringing more people to functional neurosurgery. More patients out there are aware of deep brain stimulation. In the past, people didn’t necessarily know about it. And now that they hear about focused ultrasound and they come to our clinic, they are informed about the other ways we have to target their brain. And as a result, yes, we’re doing more focused ultrasound, more people are getting functional neurosurgery, but also more DBS has been proposed and done because of the renewed interest in functional neurosurgery.
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Disclosures
Dr. Fasano has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Abbott. Dr. Fasano has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Abbvie. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ipsen. Dr. Fasano has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Medtronic. Dr. Fasano has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Boston Scientific. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Abbott. Dr. Fasano has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Medtronic. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Ceregate. Dr. Fasano has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Inbrain Neuroelectronics. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Syneos Health. Dr. Fasano has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Annovis. Dr. Fasano has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for CADTH. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for International Parkinson and Movement Disorders Society. The institution of Dr. Fasano has received research support from Boston Scientific. The institution of Dr. Fasano has received research support from Medtronic. The institution of Dr. Fasano has received research support from Abbvie. The institution of Dr. Fasano has received research support from Canadian Institutes of Health Research (CIHR). The institution of Dr. Fasano has received research support from Michael J Fox Foundation. The institution of Dr. Fasano has received research support from Bluerock Therapeutics. Dr. Fasano has received publishing royalties from a publication relating to health care. Dr. Fasano has a non-compensated relationship as a Medical Advisory Committee with CenteR for Advancing Neurological Innovation to Application (CRANIA) that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Medical Advisory Committee with HopeNET that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Medical Advisory Committee with International Essential Tremor Foundation that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Member with Tremor Research Group that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Co-Chair with Tremor Study Group of the IPMDS that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Vice-Chair with NPH Study Group of the IPMDS that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Vice-Chair with Industry Committee of the IPMDS that is relevant to AAN interests or activities.
