Essential Tremor

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Focused ultrasound treatment for essential tremor has been approved by the Food and Drug Administration (FDA) in July 2016.

Medicare approved the treatment in all US states as of July 12, 2020.

Essential tremor (ET) is the most common movement disorder, affecting an estimated 3% of the population, or approximately 10 million individuals in the United States. ET is commonly viewed as a relatively benign disease.

However, the associated disabling aspects of ET, such as significant tremor of the hands, can impair patients’ ability to eat, shave, write, perform household activities, and function in the workplace.

The underlying etiology of ET is unclear, but cases often run in families (familial tremor). It has been estimated that approximately 50% of all cases are due to a genetic mutation, and the pattern of inheritance is most consistent with autosomal dominant transmission (i.e. dominant trait).

Focused Ultrasound Therapy

Focused ultrasound is a noninvasive, therapeutic technology with the potential to improve the quality of life and decrease the cost of care for patients with essential tremor. This novel technology focuses multiple beams of ultrasound energy precisely and accurately on targets deep in the brain without damaging surrounding normal tissue.

How it Works
Where the focused ultrasound beams converge, they produce precise ablation (thermal destruction of tissue), enabling ET to be treated noninvasively. The primary target is a region in the thalamus called the ventral intermediate nucleus (Vim), but other adjacent targets and white matter pathways are also in use.

Current treatments are being performed on one side of the brain, but there is a study underway of staged bilateral treatments.


  • It is a noninvasive, single treatment that enables patients to recover rapidly and quickly return to activities of normal life (usually the next day).
  • Compared to RF ablation or DBS, focused ultrasound offers a reduced risk of infection, of damage to the non-targeted area, and of blood clot formation.
  • Focused ultrasound offers rapid resolution of symptoms.
  • In contrast to lesioning performed with stereotactic radiosurgery, focused ultrasound does not use ionizing radiation, thus avoiding the side effects of exposure to radiation.
  • Because it is non-invasive, focused ultrasound could be an option for medically refractory ET patients (those who do not respond well to medication) who do not want to undergo surgery.

Clinical Trials

clinical trial in France is using focused ultrasound to treat ET.

A multi-site US clinical trial investigating staged bilateral treatments for ET has been completed.

clinical trial in the UK and Spain is testing staged bilateral treatments. This group will treat the second side after at least nine months have passed after the first treatment.

There are two clinical trials in Canada for bilateral treatments of essential tremor. These studies are only open to Canadian Citizens.

Treatment Sites

Please see a list of possible treatment sites here.

Regulatory & Reimbursement

The Exablate system manufactured by Insightec earned FDA approval to treat essential tremor in July 2016. It is also approved for treating essential tremor in Europe, Korea, Canada, Japan, Russia, Taiwan, and the Middle East. 

In the US, all treatment sites have been approved for payment under Medicare.

Commercial coverage and Medicaid will typically follow Medicare but should be evaluated with each company and region. Some facilities have a cash payment option, for those who are not willing to wait for insurance decisions for payment. Prices vary, but a rough estimate is $40,000.

Device manufacturer, Insightec has established an informational website, including patient stories and access to treatment site information. They have also set up a Reimbursement Support Manager, who can help with questions about the status of reimbursements. Her contact information is: Kim Martin, Reimbursement Support Manager, 1-(866) 392-8478 or .

Additional Information 

Notable Papers

Suggested Reading: Focused Ultrasound: Transforming treatment of Neurodegenerative Diseases August 2022

Suggested Reading: Focused Ultrasound for Essential Tremor Market Study (2021)

Thaler C, Tian Q, WIntermark M, Ghanouni P, Halpern C, Henderson J, Airan R, Zeineh M, Goubran M, Leuze C, Fiehler J, Butts Pauly K, McNab JA. Changes In The Cerebello-thalamo-cortical Network After MR-guided Focused Ultrasound Thalamotomy. Brain Connect. 2022 Jun 9. doi: 10.1089/brain.2021.0157.

Pohl EDR, Upadhyay N, Kobeleva X, Purrer V, Maurer A, Keil VC, Kindler C, Borger V, Pieper CC, Groetz S, Scheef L, Maciaczyk J, Schild H, Vatter H, Klockgether T, Radbruch A, Attenberger U, Wüllner U, Boecker H. Coherent Structural and Functional Network Changes after Thalamic Lesions in Essential Tremor. Mov Disord. 2022 Jun 23. doi: 10.1002/mds.29130.

Erro R, Fasano A, Barone P, Bhatia KP. Milestones in Tremor Research: 10 Years Later. Mov Disord Clin Pract. 2022 Feb 26;9(4):429-435. doi: 10.1002/mdc3.13418. eCollection 2022 May.

Sasaki T, Date I. Essential Tremor That is Difficult to Improve with Standard Medical Treatment-Suppression: Surgical Treatment of Tremor. Brain Nerve. 2022 May;74(5):645-651. doi: 10.11477/mf.1416202092.

Boutet A, Loh A, Germann J, Machnowska M, Scantlebury N, Vetkas A, Elias GJB, Lozano AM, Katzberg HD, Fasano A, Schwartz ML. A Cautionary Tale of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy-Induced White Matter Lesions. Mov Disord. 2022 May 26. doi: 10.1002/mds.29040.

Purrer V, Borger V, Pohl E, Upadhyay N, Boecker H, Schmeel C, Pieper CC, Wüllner U. Transcranial high-intensity Magnetic Resonance-guided focused ultrasound (tcMRgFUS) – safety and impacts on tremor severity and quality of life. Parkinsonism Relat Disord. 2022 May 23;100:6-12. doi: 10.1016/j.parkreldis.2022.05.017.

Binder DK, Shah BB, Elias WJ. Focused ultrasound and other lesioning in the treatment of tremor. J Neurol Sci. 2022 Apr 15;435:120193. doi: 10.1016/j.jns.2022.120193. Epub 2022 Feb 19.

Alshimemeri S, Vargas-Méndez D, Chen R, Lipsman N, Schwartz ML, Lozano AM, Fasano A. Functional tremor developing after successful MRI-guided focused ultrasound thalamotomy for essential tremor. J Neurol Neurosurg Psychiatry. 2022 Apr 26:jnnp-2021-327524. doi: 10.1136/jnnp-2021-327524.

Páez-Nova M, Spiegelmann R, Korn-Israeli S, Zibly Z, Illera-Rivera D, Daza-Cordoba C, Alcazar-Daza JC, Garcia-Ballestas E. Targeting the vim by direct visualization of the cerebello-thalamo-cortical pathway in 3 T proton density MRI: correlation with focused ultrasound lesioning. Neurosurg Rev. 2022 Feb 11. doi: 10.1007/s10143-022-01752-0.

Mensah-Brown KG, Yang AI, Hitti FL, Henry L, Heman-Ackah SM, Chaibainou H, Baltuch GH. Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor Under General Anesthesia: Technical Note. Oper Neurosurg (Hagerstown). 2022 Feb 11. doi: 10.1227/ONS.0000000000000119.

Campbell JM, Ballard J, Duff K, Zorn M, Moretti P, Alexander MD, Rolston JD. Balance and cognitive impairments are prevalent and correlated with age in presurgical patients with essential tremor. Clin Park Relat Disord. 2022 Jan 23;6:100134. doi: 10.1016/j.prdoa.2022.100134. eCollection 2022.

Ahmed AK, Guo S, Kelm N, Clanton R, Melhem ER, Gullapalli RP, Ksendzovsky A, Eisenberg HM, Miller TR, Gandhi D. Technical Comparison of Treatment Efficiency of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy and Pallidotomy in Skull Density Ratio-Matched Patient Cohorts. Front Neurol. 2022 Jan 21;12:808810. doi: 10.3389/fneur.2021.808810. eCollection 2021.

Yamamoto K, Lozano AM, Fasano A. Commentary: Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor in the Setting of Prior Craniotomy. Oper Neurosurg (Hagerstown). 2022 Mar 1;22(3):e147-e149. doi: 10.1227/ONS.0000000000000087.

Wathen C, Yang AI, Hitti FL, Henry L, Chaibainou H, Baltuch GH. Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor in the Setting of Prior Craniotomy. Oper Neurosurg (Hagerstown). 2021 Dec 22. doi: 10.1227/ONS.0000000000000012.

Yuen J, Miller KJ, Klassen BT, Lehman VT, Lee KH, Kaufmann TJ. Hyperostosis in Combination With Low Skull Density Ratio: A Potential Contraindication for Magnetic Resonance Imaging-Guided Focused Ultrasound Thalamotomy. Mayo Clin Proc Innov Qual Outcomes. 2021 Dec 20;6(1):10-15. doi: 10.1016/j.mayocpiqo.2021.11.007. eCollection 2022 Feb.

Sammartino F, Yeh FC, Krishna V. Intraoperative lesion characterization after focused ultrasound thalamotomy. J Neurosurg. 2021 Dec 31:1-9. doi: 10.3171/2021.10.JNS211651.

Iorio-Morin C, Yamamoto K, Sarica C, Zemmar A, Levesque M, Brisebois S, Germann J, Loh A, Boutet A, Elias GJB, Azevedo P, Adam E, Patel U, Lenis M, Kalia SK, Hodaie M, Fasano A, Lozano AM. Bilateral Focused Ultrasound Thalamotomy for Essential Tremor (BEST-FUS Phase 2 Trial). Mov Disord. 2021 Nov;36(11):2653-2662. doi: 10.1002/mds.28716. Epub 2021 Jul 20.

Segar DJ, Lak AM, Lee S, Harary M, Chavakula V, Lauro P, McDannold N, White J, Cosgrove GR. Lesion location and lesion creation affect outcomes after focused ultrasound thalamotomy. Brain. 2021 Nov 9:awab176. doi: 10.1093/brain/awab176.

Jackson LM, Kaufmann TJ, Lehman VT, Lee KH, Miller KJ, Hassan A, Klassen BT. Clinical Characteristics of Patients with Gait Instability after MR-Guided Focused Ultrasound Thalamotomy. Tremor Other Hyperkinet Mov (N Y). 2021 Oct 21;11:41. doi: 10.5334/tohm.643. eCollection 2021.

Iijima K, Yokota H, Yamaguchi T, Nakano M, Ouchi T, Maki F, Takasaki M, Shimizu Y, Hori H, Iwamuro H, Sasanuma J, Watanabe K, Uno T. Predictors of thermal increase in magnetic resonance-guided focused ultrasound treatment for essential tremor: histogram analysis of skull density ratio values for 1024 elements. J Neurosurg. 2021 Oct 15:1-6. doi: 10.3171/2021.5.JNS21669.

Parras O, Domínguez P, Tomás-Biosca A, Guridi J. The role of tractography in the localisation of the Vim nucleus of the thalamus and the dentatorubrothalamic tract for the treatment of tremor. Neurologia (Engl Ed). 2021 Sep 23:S2173-5808(21)00142-5. doi: 10.1016/j.nrleng.2019.09.008.

Purrer V, Upadhyay N, Borger V, Pieper CC, Kindler C, Grötz S, Keil VC, Stöcker T, Boecker H, Wüllner U. Lesions of the cerebello-thalamic tract rather than the ventral intermediate nucleus determine the outcome of focused ultrasound therapy in essential tremor: A 3T and 7T MRI-study. Parkinsonism Relat Disord. 2021 Sep 20;91:105-108. doi: 10.1016/j.parkreldis.2021.09.013.

Yang AI, Hitti FL, Alabi OO, Joshi D, Chaibainou H, Henry L, Clanton R, Baltuch GH. Patient-specific effects on sonication heating efficiency during magnetic resonance-guided focused ultrasound thalamotomy. Med Phys. 2021 Sep 16. doi: 10.1002/mp.15239.

Fukutome K, Hirabayashi H, Osakada Y, Kuga Y, Ohnishi H. Bilateral Magnetic Resonance Imaging-Guided Focused Ultrasound Thalamotomy for Essential Tremor. Stereotact Funct Neurosurg. 2021 Sep 7:1-9. doi: 10.1159/000518662.

Paff M, Boutet A, Germann J, Elias GJB, Chow CT, Loh A, Kucharczyk W, Fasano A, Schwartz ML, Lozano AM. Focused Ultrasound Thalamotomy Sensory Side Effects Follow the Thalamic Structural Homunculus. Neurol Clin Pract. 2021 Aug;11(4):e497-e503. doi: 10.1212/CPJ.0000000000001013.

Maesawa S, Nakatsubo D, Tsugawa T, Kato S, Shibata M, Takai S, Torii J, Ishizaki T, Wakabayashi T, Saito R. Techniques, Indications, and Outcomes in Magnetic Resonance-guided Focused Ultrasound Thalamotomy for Tremor. Neurol Med Chir (Tokyo). 2021 Sep 1. doi: 10.2176/nmc.ra.2021-0187.

Jameel A, Gedroyc W, Nandi D, Jones B, Kirmi O, Molloy S, Tai Y, Charlesworth G, Bain P. Double lesion MRgFUS treatment of essential tremor targeting the thalamus and posterior sub-thalamic area: preliminary study with two year follow-up. Br J Neurosurg. 2021 Aug 12:1-10. doi: 10.1080/02688697.2021.1958150.

Wu P, Lin W, Li KH, Lai HC, Lee MT, Tsai KW, Chiu PY, Chang WC, Wei CY, Taira T. Focused Ultrasound Thalamotomy for the Treatment of Essential Tremor: A 2-Year Outcome Study of Chinese People. Front Aging Neurosci. 2021 Jul 14;13:697029. doi: 10.3389/fnagi.2021.697029. eCollection 2021.

Cacho-Asenjo E, Honorato-Cia C, Nuñez-Cordoba JM, Fernandez-Martinez M, Gonzalez-Quarante LH, Aviles-Olmos I, Gorospe MA, Panadero A, Rodríguez-Oroz MC, Guridi J, Martinez-Simon A. Factors Associated with Headache and Nausea During Magnetic Resonance-Guided Focused Ultrasound for Tremor. Mov Disord Clin Pract. 2021 Apr 18;8(5):701-708. doi: 10.1002/mdc3.13210. eCollection 2021 Jul.

Iorio-Morin C, Yamamoto K, Sarica C, Zemmar A, Levesque M, Brisebois S, Germann J, Loh A, Boutet A, Elias GJB, Azevedo P, Adam E, Patel U, Lenis M, Kalia SK, Hodaie M, Fasano A, Lozano AM. Bilateral Focused Ultrasound Thalamotomy for Essential Tremor (BEST-FUS Phase 2 Trial). Mov Disord. 2021 Jul 20. doi: 10.1002/mds.28716.

De Vloo P, Boutet A, Elias GJB, Gramer RM, Joel SE, Llinas M, Kucharczyk W, Fasano A, Hamani C, Lozano AM. Dysgeusia induced and resolved by focused ultrasound thalamotomy: case report. J Neurosurg. 2021 Jun 18:1-6. doi: 10.3171/2020.11.JNS202882.

Agrawal M, Garg K, Samala R, Rajan R, Naik V, Singh M. Outcome and Complications of MR Guided Focused Ultrasound for Essential Tremor: A Systematic Review and Meta-Analysis. Front Neurol. 2021 May 7;12:654711. doi: 10.3389/fneur.2021.654711. eCollection 2021.

Kim MJ, Park SH, Chang KW, Kim Y, Gao J, Kovalevsky M, Rachmilevitch I, Zadicario E, Chang WS, Jung HH, Chang JW. Technical and operative factors affecting magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: experience from 250 treatments. J Neurosurg. 2021 May 21:1-9. doi: 10.3171/2020.11.JNS202580.

Miller WK, Becker KN, Caras AJ, Mansour TR, Mays MT, Rashid M, Schwalb J. Magnetic resonance-guided focused ultrasound treatment for essential tremor shows sustained efficacy: a meta-analysis.** Neurosurg Rev. 2021 May 12. doi: 10.1007/s10143-021-01562-w.

Jameel A, Bain P, Nandi D, Jones B, Gedroyc W. Device profile of exAblate Neuro 4000, the leading system for brain magnetic resonance guided focused ultrasound technology: an overview of its safety and efficacy in the treatment of medically refractory essential tremor. Expert Rev Med Devices. 2021 May 13:1-9. doi: 10.1080/17434440.2021.1921572.

Varma-Doyle AV, Villemarette-Pittman NR, Copeland BJ. Hemi-parkinsonism and return of essential tremors after MRgFUS thalamotomy: Case report and review of procedural complications affecting ventral thalamic nuclei. eNeurologicalSci. 2021 Apr 13;23:100339. doi: 10.1016/j.ensci.2021.100339. eCollection 2021 Jun.

Martínez-Fernández R, Mahendran S, Pineda-Pardo JA, Imbach LL, Máñez-Miró JU, Büchele F, Del Álamo M, Rodriguez-Rojas R, Hernández-Fernández F, Werner B, Matarazzo M, Obeso I, Gonzalez-Quarante LH, Deuschl G, Stieglitz L, Baumann CR, Obeso JA. Bilateral staged magnetic resonance-guided focused ultrasound thalamotomy for the treatment of essential tremor: a case series study. J Neurol Neurosurg Psychiatry. 2021 Apr 27:jnnp-2020-325278. doi: 10.1136/jnnp-2020-325278.

Iorio-Morin C, Hodaie M, Lozano AM. Adoption of focused ultrasound thalamotomy for essential tremor: why so much fuss about FUS? J Neurol Neurosurg Psychiatry. 2021 Feb 9:jnnp-2020-324061. doi: 10.1136/jnnp-2020-324061.

Chang KW, Rachmilevitch I, Chang WS, Jung HH, Zadicario E, Prus O, Chang JW. Safety and Efficacy of Magnetic Resonance-Guided Focused Ultrasound Surgery With Autofocusing Echo Imaging. Front Neurosci. 2021 Jan 12;14:592763. doi: 10.3389/fnins.2020.592763. eCollection 2020.

Abe K, Horisawa S, Yamaguchi T, Hori H, Yamada K, Kondo K, Furukawa H, Kamada H, Kishima H, Oshino S, Mochizuki H, Kanemoto M, Hirabayashi H, Fukutome K, Ohnishi H, Igase K, Matsubara I, Ohnishi T, Sadamoto K, Taira T. Focused Ultrasound Thalamotomy for Refractory Essential Tremor: A Japanese Multicenter Single-Arm Study. Neurosurgery. 2021 Jan 19:nyaa536. doi: 10.1093/neuros/nyaa536.

Click here for additional references from PubMed.

Pre- and post-treatment assessment videos courtesy of University of Virginia

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