Thalamic Deep Brain Stimulation for Orthostatic Tremor

Abstract

Background: Orthostatic tremor is an uncommon disorder manifest by high frequency, low amplitude leg tremor upon weight bearing. Treatment with oral tremor agents is inconsistent and usually not satisfactory.Methods: We implanted bilateral ventralis intermedius nuclei deep brain stimulators into an 82-year-old male with refractory orthostatic tremor. Results:The patient had a marked subjective and objective improvement in leg and arm tremor, mainly manifested by an improved ability to stand.Discussion: Bilateral thalamic deep brain stimulation may be considered in refractory cases of orthostatic tremor.

Orthostatic tremor: a cerebellar pathology?

“…In a single case study using fluorodeoxyglucose (FDG)-PET, a patient with a orthostatic tremor had bilateral primary motor cortex and cerebellar vermis hypermetabolism, which returned to normal when the tremor was suppressed by deep brain stimulation of the ventral intermediate nucleus of the thalamus receiving cerebellar inputs ( Guridi et al , 2008 ). In the same line of evidence, bilateral stimulation of the ventral intermediate nucleus partially improved orthostatic tremor in other studies ( Espay et al , 2008 ; Guridi et al , 2008 ; Magariños-Ascone et al , 2010 ; Yaltho and Ondo, 2011 ; Lyons et al , 2012 ; Contarino et al , 2015 ). Yet the improvement was less obvious than in essential tremor, suggesting that the pathophysiology of orthostatic tremor and essential tremor engages different parts of the cerebellar motor loops or different pathways.…”

Orthostatic Tremor: An Update on a Rare Entity

“…66 Sixth, cerebellar outflow (dentato-rubro-thalamic) pathways are the target of deep brain stimulation, which may be effective in treating OT. 10,[78][79][80][81][82][83][84] Finally, the tremors recorded in each leg have a high coherence. In other words, they have an almost constant phase relationship, which is not typical for most other pathological tremors.…”

“…However, bilateral ventral intermediate thalamic nucleus stimulation could provide long-lasting relief of symptoms in some patients with medication-resistant OT. 10,[78][79][80][81][82][83][84] Nonetheless, in another patient who was treated with unilateral deep brain stimulation of the ventral intermediate thalamic nucleus, clinical benefits receded after 3 months. 78 Alternatively, chronic spinal cord stimulation has demonstrated a beneficial effect with long-term follow-up in a few patients with medically intractable primary OT.…”

Deep brain stimulation for the treatment of uncommon tremor syndromes

“… Author Target Outcome Follow-up Espay et al (2008) [ 105 ] Two patients with bilateral VIM and unilateral (right) DBS Marked clinical improvement in patient with bilateral procedure. Patient with unilateral DBS noted tremor recurrence at 3 months 18 months Guridi et al (2008) [ 103 ] One patient with bilateral VIM DBS Marked cessation of tremor bilaterally 4 years Magarinos-Ascone et al (2010) [ 106 ] One patient with bilateral VIM DBS The patient could stand normally without any help or leg tremor 12 months Yaltho et al (2010) [ 107 ] One patient with bilateral VIM DBS Marked improvement in both his OT and hand tremor, ability to stand improve from 35 s to 4 min 6 months Lyons et al (2012) [ 108 ] One patient with bilateral VIM DBS Subjective improvement of 80% in OT in left leg and 50% improvement in right leg. Patient was able to stand in place for 7 min before needing to sit 30 months Contarino, et al (2015) [ 109 ] One patient with bilateral VIM DBS Marked symptomatic improvement which gradually decreased over time 5 years Hassan et al (2016) [ 110 ] Two patients with bilateral VIM DBS Good response immediately postoperatively, improved standing ability and reduction of OT severity 3 years Coleman et al (2016) [ 111 ] Two patients with bilateral VIM DBS Improvement in standing time patient 1: 50 s at baseline to 15 min and patient 2: 34 s at baseline to 4.2 min 16 months and 7 months, respectively VIM, ventral intermed...…”