10 Years Follow‐Up of Deep Brain Stimulation in the Caudal Zona Incerta/Posterior Subthalamic Area for Essential Tremor

Blomstedt, Yulia; Persson, Rasmus Stenmark; Awad, Amar; Hariz, Gun‐Marie; Philipson, Johanna; Hariz, Marwan; Fytagoridis, Anders; Blomstedt, Patric

doi:10.1002/mdc3.13729

Cited by 6 publications

(5 citation statements)

References 41 publications

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“…We do not routinely target the cZI for SRS thalamotomy purposes. However, we recognize that DBS of the cZI or Vim ± cZI is now a well-acknowledged DBS target for drug-resistant ET [ 5 , 9 ].…”

Section: Discussionmentioning

confidence: 99%

Impact of biologically effective dose on tremor decrease after stereotactic radiosurgical thalamotomy for essential tremor: a retrospective longitudinal analysis

Tuleasca,

Carey,

Barriol

et al. 2024

Neurosurg Rev

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Stereotactic radiosurgery (SRS) is one of the surgical alternatives for drug-resistant essential tremor (ET). Here, we aimed at evaluating whether biologically effective dose (BEDGy2.47) is relevant for tremor improvement after stereotactic radiosurgical thalamotomy in a population of patients treated with one (unplugged) isocenter and a uniform dose of 130 Gy. This is a retrospective longitudinal single center study. Seventy-eight consecutive patients were clinically analyzed. Mean age was 69.1 years (median 71, range 36–88). Mean follow-up period was 14 months (median 12, 3–36). Tremor improvement was assessed at 12 months after SRS using the ET rating assessment scale (TETRAS, continuous outcome) and binary (binary outcome). BED was defined for an alpha/beta of 2.47, based upon previous studies considering such a value for the normal brain. Mean BED was 4573.1 Gy2.47 (median 4612, 4022.1–4944.7). Mean beam-on time was 64.7 min (median 61.4; 46.8–98.5). There was a statically significant correlation between delta (follow-up minus baseline) in TETRAS (total) with BED (p = 0.04; beta coefficient − 0.029) and beam-on time (p = 0.03; beta coefficient 0.57) but also between TETRAS (ADL) with BED (p = 0.02; beta coefficient 0.038) and beam-on time (p = 0.01; beta coefficient 0.71). Fractional polynomial multivariate regression suggested that a BED > 4600 Gy2.47 and a beam-on time > 70 min did not further increase clinical efficacy (binary outcome). Adverse radiation events (ARE) were defined as larger MR signature on 1-year follow-up MRI and were present in 7 out of 78 (8.9%) cases, receiving a mean BED of 4650 Gy2.47 (median 4650, range 4466–4894). They were clinically relevant with transient hemiparesis in 5 (6.4%) patients, all with BED values higher than 4500 Gy2.47. Tremor improvement was correlated with BED Gy2.47 after SRS for drug-resistant ET. An optimal BED value for tremor improvement was 4300–4500 Gy2.47. ARE appeared for a BED of more than 4500 Gy2.47. Such finding should be validated in larger cohorts.

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Section: Discussionmentioning

confidence: 99%

Impact of biologically effective dose on tremor decrease after stereotactic radiosurgical thalamotomy for essential tremor: a retrospective longitudinal analysis

Tuleasca,

Carey,

Barriol

et al. 2024

Neurosurg Rev

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“…Lesional PSA surgery is known to be effective for tremors in general and has been used in many rare tremor cases [14]. Open studies and two recent randomized blinded trials have suggested that DBS of the cZI/PSA is superior to VIM DBS in terms of tremor relief and current efficiency [4,24,43,45,62,63]. For rare tremor syndromes, the number of reports is very limited [5].…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, some recent research has suggested this to be a promising effective treatment [5,20,21]. However, there have not yet been any studies on double targeting of the VIM and PSA [22][23][24][25][26]. In the current study, we applied such double targeting to several rare tremor conditions to determine the efficacy and safety of the procedure.…”

Section: Introductionmentioning

confidence: 99%

Deep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor Syndromes

Yilmaz,

Eray,

Cakir

et al. 2024

Stereotact Funct Neurosurg

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Introduction: In tremor syndromes, pharmacological therapy is the primary treatment, but deep brain stimulation (DBS) is used when it is insufficient. We explore the use of DBS, focusing on the globus pallidus internus for dystonia and the ventral intermediate nucleus (VIM) for tremor conditions. We introduce the posterior subthalamic area (PSA) as a potential target, suggesting its efficacy in tremor reduction, particularly in rare tremor syndromes. We aim to evaluate the efficacy and safety of double targeting the VIM and PSA in rare tremor conditions, highlighting the limited existing data on this. Methods: Between 2019 and 2023, 22 patients with rare tremor syndromes were treated with bilateral DBS of the VIM and PSA. This case series consisted of 7 isolated head tremor, 1 hepatic encephalopathic tremor due to Abernethy syndrome, 2 voice tremor, 4 dystonic tremor, and 8 Holmes tremor (2 multiple sclerosis, 2 cerebellar insult, and 4 posttraumatic) patients. Patients’ preoperative and 12-month postoperative tremor scores were compared, and the optimum VIM and PSA stimulation areas were investigated. Results: There was a significant reduction in the mean TRS score from 3.70 (±0.57) to 0.45 (±0.68) after 12 months of surgery. Specific outcomes for different indications were observed: for head tremor, 6 of 7 patients showed a reduction in TRS scores to 0 points; the vocal tremor patients demonstrated improvement; this change was not statistically significant, which is likely to be due to the low number of patients in this subgroup; the dystonic tremor patients showed either complete tremor abolition or a reduction in TRS scores; the Holmes tremor patients showed an 80% reduction in TRS scores; and the hepatic encephalopathy tremor and Abernethy syndrome patients showed a 75% improvement in TRS scores. The stimulation parameters converged on the VIM and dorsal PSA. Complications included the need for electrode repositioning, infections requiring electrode removal and re-implantation, dysarthria, and stimulation-induced ataxia, which was resolved by adjusting the stimulation parameters. Discussion: The literature on DBS for rare tremors is limited. Double targeting of the VIM and PSA appears to produce promising improvements on the outcomes reported in the existing literature on VIM-only DBS. The proximity of the VIM and PSA allows for flexible electrode placement, contributing to the potential success of the dual-target approach. We also discuss the theoretical advantages of targeting the PSA based on the distribution of tremor circuits, emphasizing the need for further research and electrophysiological studies.

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“…Other targets, such as the posterior subthalamic area and the caudal zona incerta, have also been investigated to manage the essential tremor motor symptoms. However, the data available for these targets are limited [51].…”

Section: Essential Tremormentioning

confidence: 99%

Deep Brain Stimulation for the Management of Refractory Neurological Disorders: A Comprehensive Review

Rissardo,

Vora,

Tariq

et al. 2023

Medicina

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In recent decades, deep brain stimulation (DBS) has been extensively studied due to its reversibility and significantly fewer side effects. DBS is mainly a symptomatic therapy, but the stimulation of subcortical areas by DBS is believed to affect the cytoarchitecture of the brain, leading to adaptability and neurogenesis. The neurological disorders most commonly studied with DBS were Parkinson’s disease, essential tremor, obsessive-compulsive disorder, and major depressive disorder. The most precise approach to evaluating the location of the leads still relies on the stimulus-induced side effects reported by the patients. Moreover, the adequate voltage and DBS current field could correlate with the patient’s symptoms. Implantable pulse generators are the main parts of the DBS, and their main characteristics, such as rechargeable capability, magnetic resonance imaging (MRI) safety, and device size, should always be discussed with patients. The safety of MRI will depend on several parameters: the part of the body where the device is implanted, the part of the body scanned, and the MRI-tesla magnetic field. It is worth mentioning that drug-resistant individuals may have different pathophysiological explanations for their resistance to medications, which could affect the efficacy of DBS therapy. Therefore, this could explain the significant difference in the outcomes of studies with DBS in individuals with drug-resistant neurological conditions.

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10 Years Follow‐Up of Deep Brain Stimulation in the Caudal Zona Incerta/Posterior Subthalamic Area for Essential Tremor

Cited by 6 publications

References 41 publications

Impact of biologically effective dose on tremor decrease after stereotactic radiosurgical thalamotomy for essential tremor: a retrospective longitudinal analysis

Impact of biologically effective dose on tremor decrease after stereotactic radiosurgical thalamotomy for essential tremor: a retrospective longitudinal analysis

Deep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor Syndromes

Deep Brain Stimulation for the Management of Refractory Neurological Disorders: A Comprehensive Review

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