Staged bilateral MR-guided focused ultrasound thalamotomy in a patient with cerebral cavernous malformations

MRI-guided focused ultrasound (MRgFUS) thalamotomy is an effective ablative procedure for medication-refractory essential tremor (ET). However, limited data exist regarding its safety in patients with coexisting intracranial disease such as cerebral cavernous malformations. We present a man in his late 60s with medication-refractory ET who underwent staged bilateral MRgFUS thalamotomy. Preoperative MRI demonstrated heterogeneously T1-hyperintense and T2-hyperintense lesions in the left caudate head and basal ganglia consistent with cavernous malformations, with an associated developmental venous anomaly and no prior haemorrhage. After individualised counselling regarding unknown procedural risks, the patient underwent right-sided thalamotomy, followed 1 year later by left-sided thalamotomy. MRI after each procedure demonstrated expected treatment-related changes without acute intracranial haemorrhage around the cavernous malformations. This case demonstrates successful staged bilateral MRgFUS thalamotomy in a patient with cerebral cavernous malformations, suggesting they may not uniformly preclude MRgFUS in carefully selected patients. Preoperative planning, counselling and MRI surveillance remain essential.