Neurosurgery notes/Procedures/Cranial procedures/Functional cranial procedures/Cranial stimulation/DBS target/DBS target for movement disorders/DBS for essential tremor

DBS for essential tremor

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DBS target for movement disorders
  • Indication
    • Medical treatment resistant tremor
    • Needs to be impacting quality of life severely
    • Tremor amplitude of around 2-3 cm
    • Lack of significant cognitive or neuropsychiatric vulnerabilities
    • Good speech and gait (both can be worsen post-op with DBS due to stimulation side effects although are reversible)
  • Target
    • Ventro-intermedius nucleus (Vim) of the thalamus
      • For
        • Essential tremor
        • Tremor dominant PD
        • Other types of tremor
      • Side effects of a subset of patients after several years of chronic stimulation: (Especially with bilateral stimulation)
        • Habituation
          • Loss of benefit is sometimes observed over time.
        • Dysarthria
        • Gait ataxia/disequilibrium
          • The very mild cerebellar ataxia displayed by ET patients may also be improved by the stimulation of the posterior subthalamic area (STA), beneath the inferior border of the Vim, where the dentato-thalamic tract runs
            • conversely strong stimulation worsens cerebellar side effects.
  • Technique
        • VIM DBS for Tremor Coordinate based targeting MCP Coordinates: L: 10 - 11 from ventricle AP: 1/2 betw. PC and MCP Awake Image based targeting target Intraoperative clinical testing L"Ed % *ago Layrd 11.0 mm
        Motor Thalamus - VIM Image-based targeting of the VIM? 7 Tesla post mortem scan L."ard Hgo Lay*d Hor" 1.5 Tesla Proton Density scan
        A screenshot of a computer AI-generated content may be incorrect.
        VIM DBS for Tremor Anterior Vop Voa Voa Globus pallidus Medial CM/Pf top} , STN Vim Pulvinar Hugo Layard Hugo Layard Horsfag Voa = ventral oral anterior Vop = ventral oral posterior Vim = ventral intermedium nucleus Vc/Vp = Ventral caudal / Ventral posterior VPL = ventral posterior lateral VPM = ventral posterior medial DRT = dentato-rubro thalamic tract Posterior VC / VP (sensory thalamus) Spinothalmic tract (to VPL) Trigemino-thalamic tract (to VPM) Dentato-rubro-thalamic tract (DRT) from Dentate (Cerebellum) Lateral Capsula interna
        VIM DBS for Tremor Anterior Vop: More amplitude Voa: No effect on tremor Hugo Layud Hugo Horsfall Medial CM/Pf: No effect on tremor Laterai Dos V,op Vim ,zvc ulvi STN Lateral Internal Capsule: Dysarthria, muscle contraction Posterior Sensory thalamus tingling Deeper Zona Incerta: Reduction in Tremor DRT: Reduction in Tremor Medial lemniscus: Paresthesias Internal Capsule: Dysarthria, Muscle contractions
      • You want to get some tingling in the hand and not in the mouth and legs
  • Outcome
    • Initially 80% improvement
    • Long term 40%
    • VIM DBS for Tremor
        • Epidemiology ET:
          • Prevalence: 0.4 – 0.9%
          • Male > female
        • Pathophysiology:
          • Unknown
          • Genetic
        • Cardinal Symptom:
          • Intention tremor
        • Treatment
          • Medications
          • DBS
            • Tremor not well controlled with meds or side-effects from meds
            • Interferes with patient's quality of life
        • Outcome:
          • Initially > 80 - 90%
          • Longer term: 60% – 80%
          • Long term: 40% – 70%
        VIM DBS for Tremor Epidemiology ET: Prevalence: 0.4 — 0.9% male > female Pathophysiologie: unknown genetic Cardinal Symptom: Intention tremor Treatment Medications DBS DBS: Tremor not well controlled with meds or side-effects from meds Interferes with patient's quality of life Outcome: Initially > 80 - Longer term. Long term: 40% — 70% 35 30 25 20 15 10 5 o stim pre-op. n=68 stim 6 months n=67 Layud Horsfan Tremor-score grade 4 grade 3 ngrade 2 Ograde 1 •grade O stim 2 years n = 66 Movement Disorders vol. 23, No. S. 2008. pp. 1146-1153
        VIM DBS for Tremor Epidemiology ET: Prevalence: 0.4 — 0.9% male > female Pathophysiologie: unknown genetic Cardinal Symptom: Intention tremor Treatment Medications DBS DBS: Tremor not well controlled with meds or side-effects from meds Interferes with patient's quality of life Outcome: Initially > 80 - Longer term. Long term: 40% — 70% 35 30 25 20 15 10 5 o stim pre-op. n=68 stim 6 months n=67 Layud Horsfan Tremor-score grade 4 grade 3 ngrade 2 Ograde 1 •grade O stim 2 years n = 66 Movement Disorders vol. 23, No. S. 2008. pp. 1146-1153
  • Other tremor
    • MS related tremor
      • Trial ongoing
      • Target:
        • Thalamic