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Paschen S, Becktepe JS, Hobert MA, Zeuner KE, Helmers A, Berg D, Deuschl G. The Challenge of Choosing the Right Stimulation Target for Dystonic Tremor-A Series of Instructive Cases. Mov Disord Clin Pract 2023; 10:1478-1484. [PMID: 37868912 PMCID: PMC10585974 DOI: 10.1002/mdc3.13846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/14/2023] [Accepted: 07/08/2023] [Indexed: 10/24/2023] Open
Abstract
Background Thalamic deep brain stimulation (DBS) is established for medically refractory tremor syndromes and globus pallidus stimulation (GPi-DBS) for medically refractory dystonia syndromes. For combined tremor and dystonia syndromes, the best target is unclear. Objectives We present four patients with two different profiles whose clinical course demonstrates that our current analysis of clinical symptomatology is not a sufficient predictor of surgical success. Methods Outcome parameters were assessed with observer-blinded video ratings and included the Fahn-Tolosa-Marin-Tremor Rating Scale (FTM-TRS) and the Unified Dystonia Rating Scale (UDRS). Results Two patients with "predominant lateralized action tremor" of the hands and mild cervical dystonia showed no relevant tremor improvement after GPi-DBS, but UDRS improved (mean, 45%). Rescue ventral intermediate nucleus of the thalamus (Vim)-DBS electrodes were implanted and both patients benefited significantly with a mean tremor reduction of 51%.Two other patients with "axial-predominant action tremor of the trunk and head" associated with cervical dystonia underwent bilateral Vim-DBS implantation with little effect on tremor (24% reduction in mean FTM-TRS total score) and no effect on dystonic symptoms. GPi rescue DBS was implanted and showed a significant effect on tremor (63% reduction in mean FTM-TRS) and dystonia (49% reduction in UDRS). Conclusions The diagnosis of dystonic tremor alone is not a sufficient predictor to establish the differential indication of GPi- or Vim-DBS. Further criteria (eg, proximal-distal distribution of tremor/dystonia) are needed to avoid rescue surgery in the future. On the other hand, the course of our patients encourages rescue surgery in such severely disabled patients if the first target fails.
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Affiliation(s)
- Steffen Paschen
- Department of NeurologyUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
| | - Jos S. Becktepe
- Department of NeurologyUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
| | - Markus A. Hobert
- Department of NeurologyUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
| | - Kirsten E. Zeuner
- Department of NeurologyUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
| | - Ann‐Kristin Helmers
- Department of NeurosurgeryUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
| | - Daniela Berg
- Department of NeurologyUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
| | - Günther Deuschl
- Department of NeurologyUniversity Hospital Schleswig‐Holstein, Campus Kiel and Christian Albrechts‐University of KielKielGermany
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Trompette C, Giordana C, Leplus A, Grabli D, Hubsch C, Marsé C, Fontaine D. Combined thalamic and pallidal deep brain stimulation for dystonic tremor. Parkinsonism Relat Disord 2022; 103:29-33. [PMID: 36029608 DOI: 10.1016/j.parkreldis.2022.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/30/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) has been proposed to treat disabling dystonic tremor (DT), but there is debate about the optimal target. DBS of the globus pallidus interna (GPi) may be insufficient to control tremor, and DBS of the ventral intermediate thalamic nucleus (VIM) may inadequately control dystonic features, raising the question of combining both targets. OBJECTIVES To report the respective effects on DT symptoms of high-frequency stimulation of the VIM, the GPi and both targets simultaneously stimulated. METHODS Three patients with DT treated by bilateral high frequency DBS of 2 targets (VIM and GPi) were assessed 12 months after surgery in 4 conditions (VIM and GPi-DBS; GPi-DBS only; VIM-DBS only; DBS switched Off for both targets) by 3 independent movement disorders specialists blinded to the condition. RESULTS The Fahn-Tolosa-Marin-tremor-rating-scale (FTM-TRS) and Burke-Fahn-Marsden-dystonia-rating-scale (BFM-DRS) scores were more improved by combined DBS than VIM alone or GPi alone. Compared to Off/Off condition, mean total FTM-TRS score decrease was 34%, 42% and 63% respectively with VIM only, GPi only and combined VIM and GPi stimulation. Mean total BFM-DRS score decrease was 34%, 37% and 60% respectively with VIM only, GPi only and combined VIM and GPi stimulation, compared to Off/Off condition. Improvement concerned both motor, functional and activities of daily living sub-scores. No complications or adverse events were observed. CONCLUSION Combined VIM- and GPi-DBS, by modulating the cerebello-thalamo-cortical network and the basal ganglia-thalamo-cortical network, both involved in DT pathophysiology, may be more efficient than single DBS targeting only one of them.
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Affiliation(s)
- Caroline Trompette
- Department of Neurology, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Caroline Giordana
- Department of Neurology, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France.
| | - Aurélie Leplus
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - David Grabli
- Sorbonne Université, Paris Brain Institute, Inserm, CNRS, Paris, France; Department of Neurology, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Cécile Hubsch
- Parkinson Unit, Department of Neurology, Hospital Foundation Adolphe de Rothschild, Paris, France
| | - Claire Marsé
- Department of Neurology, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Denys Fontaine
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France; UR2CA, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
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Nieuwhof F, Toni I, Buijink AW, van Rootselaar AF, van de Warrenburg BP, Helmich RC. Phase-locked transcranial electrical brain stimulation for tremor suppression in dystonic tremor syndromes. Clin Neurophysiol 2022; 140:239-250. [DOI: 10.1016/j.clinph.2022.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/19/2022]
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4
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Nieuwhof F, Toni I, Dirkx MF, Gallea C, Vidailhet M, Buijink AWG, van Rootselaar AF, van de Warrenburg BPC, Helmich RC. Cerebello-thalamic activity drives an abnormal motor network into dystonic tremor. Neuroimage Clin 2021; 33:102919. [PMID: 34929584 PMCID: PMC8688717 DOI: 10.1016/j.nicl.2021.102919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 01/18/2023]
Abstract
Dystonic tremor syndromes are highly burdensome and treatment is often inadequate. This is partly due to poor understanding of the underlying pathophysiology. Several lines of research suggest involvement of the cerebello-thalamo-cortical circuit and the basal ganglia in dystonic tremor syndromes, but their role is unclear. Here we aimed to investigate the contribution of the cerebello-thalamo-cortical circuit and the basal ganglia to the pathophysiology of dystonic tremor syndrome, by directly linking tremor fluctuations to cerebral activity during scanning. In 27 patients with dystonic tremor syndrome (dystonic tremor: n = 23; tremor associated with dystonia: n = 4), we used concurrent accelerometery and functional MRI during a posture holding task that evoked tremor, alternated with rest. Using multiple regression analyses, we separated tremor-related activity from brain activity related to (voluntary) posture holding. Using dynamic causal modelling, we tested for altered effective connectivity between tremor-related brain regions as a function of tremor amplitude fluctuations. Finally, we compared grey matter volume between patients (n = 27) and matched controls (n = 27). We found tremor-related activity in sensorimotor regions of the bilateral cerebellum, contralateral posterior and anterior ventral lateral nuclei of the thalamus (VLp and VLa), contralateral primary motor cortex (hand area), contralateral pallidum, and the bilateral frontal cortex (laterality with respect to the tremor). Grey matter volume was increased in patients compared to controls in the portion of contralateral thalamus also showing tremor-related activity, as well as in bilateral medial and left lateral primary motor cortex, where no tremor-related activity was present. Effective connectivity analyses showed that inter-regional coupling in the cerebello-thalamic pathway, as well as the thalamic self-connection, were strengthened as a function of increasing tremor power. These findings indicate that the pathophysiology of dystonic tremor syndromes involves functional and structural changes in the cerebello-thalamo-cortical circuit and pallidum. Deficient input from the cerebellum towards the thalamo-cortical circuit, together with hypertrophy of the thalamus, may play a key role in the generation of dystonic tremor syndrome.
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Affiliation(s)
- Freek Nieuwhof
- Centre for Cognitive Neuroimaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500 HB Nijmegen, the Netherlands
| | - Ivan Toni
- Centre for Cognitive Neuroimaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500 HB Nijmegen, the Netherlands
| | - Michiel F Dirkx
- Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, 6500 HB Nijmegen, the Netherlands
| | - Cecile Gallea
- MOV'IT Section (Movement Investigations and Therapeutics), Paris Brain Institute (CNRS/INSERM UMR 7225/1127), Sorbonne Université, 75013 Paris, France
| | - Marie Vidailhet
- Institut du Cerveau et de la Moelle épinière (ICM) UMR 1127, Hôpital de la Pitié-Salpétrière, Department of Neurology, AP-HP, Sorbonne Université, 75013 Paris, France
| | - Arthur W G Buijink
- Department of Neurology, Amsterdam University Medical Centers, 1105 AZ Amsterdam Neuroscience, University of Amsterdam, Amsterdam, the Netherlands
| | - Anne-Fleur van Rootselaar
- Department of Neurology, Amsterdam University Medical Centers, 1105 AZ Amsterdam Neuroscience, University of Amsterdam, Amsterdam, the Netherlands
| | - Bart P C van de Warrenburg
- Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, 6500 HB Nijmegen, the Netherlands
| | - Rick C Helmich
- Centre for Cognitive Neuroimaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500 HB Nijmegen, the Netherlands; Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, 6500 HB Nijmegen, the Netherlands.
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Tsuboi T, Wong JK, Eisinger RS, Okromelidze L, Burns MR, Ramirez-Zamora A, Almeida L, Wagle Shukla A, Foote KD, Okun MS, Grewal SS, Middlebrooks EH. Comparative connectivity correlates of dystonic and essential tremor deep brain stimulation. Brain 2021; 144:1774-1786. [PMID: 33889943 DOI: 10.1093/brain/awab074] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/25/2021] [Accepted: 02/15/2021] [Indexed: 11/14/2022] Open
Abstract
The pathophysiology of dystonic tremor and essential tremor remains partially understood. In patients with medication-refractory dystonic tremor or essential tremor, deep brain stimulation (DBS) targeting the thalamus or posterior subthalamic area has evolved into a promising treatment option. However, the optimal DBS targets for these disorders remains unknown. This retrospective study explored the optimal targets for DBS in essential tremor and dystonic tremor using a combination of volumes of tissue activated estimation and functional and structural connectivity analyses. We included 20 patients with dystonic tremor who underwent unilateral thalamic DBS, along with a matched cohort of 20 patients with essential tremor DBS. Tremor severity was assessed preoperatively and approximately 6 months after DBS implantation using the Fahn-Tolosa-Marin Tremor Rating Scale. The tremor-suppressing effects of DBS were estimated using the percentage improvement in the unilateral tremor-rating scale score contralateral to the side of implantation. The optimal stimulation region, based on the cluster centre of gravity for peak contralateral motor score improvement, for essential tremor was located in the ventral intermediate nucleus region and for dystonic tremor in the ventralis oralis posterior nucleus region along the ventral intermediate nucleus/ventralis oralis posterior nucleus border (4 mm anterior and 3 mm superior to that for essential tremor). Both disorders showed similar functional connectivity patterns: a positive correlation between tremor improvement and involvement of the primary sensorimotor, secondary motor and associative prefrontal regions. Tremor improvement, however, was tightly correlated with the primary sensorimotor regions in essential tremor, whereas in dystonic tremor, the correlation was tighter with the premotor and prefrontal regions. The dentato-rubro-thalamic tract, comprising the decussating and non-decussating fibres, significantly correlated with tremor improvement in both dystonic and essential tremor. In contrast, the pallidothalamic tracts, which primarily project to the ventralis oralis posterior nucleus region, significantly correlated with tremor improvement only in dystonic tremor. Our findings support the hypothesis that the pathophysiology underpinning dystonic tremor involves both the cerebello-thalamo-cortical network and the basal ganglia-thalamo-cortical network. Further our data suggest that the pathophysiology of essential tremor is primarily attributable to the abnormalities within the cerebello-thalamo-cortical network. We conclude that the ventral intermediate nucleus/ventralis oralis posterior nucleus border and ventral intermediate nucleus region may be a reasonable DBS target for patients with medication-refractory dystonic tremor and essential tremor, respectively. Uncovering the pathophysiology of these disorders may in the future aid in further improving DBS outcomes.
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Affiliation(s)
- Takashi Tsuboi
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.,Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Joshua K Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Robert S Eisinger
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | | | - Mathew R Burns
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kelly D Foote
- Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | | | - Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
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Yamahata H, Horisawa S, Hodotsuka K, Kawamata T, Taira T. Long-Term Successful Outcome of Dystonic Head Tremor after Bilateral Deep Brain Stimulation of the Ventral Intermediate and Ventro-Oral Internus Nuclei: A Case Report and Literature Review of Dystonic Head Tremor. Stereotact Funct Neurosurg 2021; 99:107-112. [PMID: 33401264 DOI: 10.1159/000510593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/30/2020] [Indexed: 11/19/2022]
Abstract
Head tremor in patients with dystonia is referred to as dystonic tremor. During surgical treatment, numerous targets may be selected, including the internal segment of the globus pallidus and the ventral intermediate (Vim) nucleus; however, there is no consensus concerning the most effective treatment target. We report herein a case of dystonic head tremor in which improvement persisted for 5 years after deep brain stimulation (DBS) of the bilateral thalamic Vim and ventro-oral internus (Voi) nuclei. The patient, a 67-year-old woman, has a horizontal head tremor associated with cervical dystonia that had been resistant to drug treatment over 3 years. Immediately following surgery, dystonia and tremor symptoms had completely improved. Voice volume declined and dysarthria occurred but improved upon adjusting the stimulation conditions. Over 5 years, both head tremor and cervical dystonia have been completely controlled, and no other obvious complications have been observed. As the Voi nucleus receives pallidothalamic projections involved in dystonia and the Vim nucleus receives cerebellothalamic projections involved in tremors, stimulating these 2 nuclei with the same electrode appears reasonable in the treatment of dystonic tremor. This case suggests that Vim-Voi DBS may be effective for treating dystonic head tremor.
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Affiliation(s)
- Hayato Yamahata
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Shiro Horisawa
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan,
| | - Kenichi Hodotsuka
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
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7
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Tsuboi T, Au KLK, Deeb W, Almeida L, Foote KD, Okun MS, Ramirez-Zamora A. Motor outcomes and adverse effects of deep brain stimulation for dystonic tremor: A systematic review. Parkinsonism Relat Disord 2020; 76:32-41. [PMID: 32559631 DOI: 10.1016/j.parkreldis.2020.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/13/2020] [Accepted: 06/05/2020] [Indexed: 12/22/2022]
Abstract
Dystonic tremor (DT) is defined as the tremor in body parts affected by dystonia. Although deep brain stimulation (DBS) has been used to manage medically-refractory DT patients, its efficacy has not been well established. The objective of this study is to provide an up-to-date systematic review of DBS outcomes for DT patients. We conducted a literature search using Medline, Embase, and Cochrane Library databases in February 2020 according to the PRISMA guidelines. From 858 publications, we identified 30 articles involving 89 DT patients who received DBS of different targets. Thalamic DBS was the most common (n = 39) and improved tremor by 40-50% potentially in the long-term over five years with variable effects on dystonic symptoms. Globus pallidus internus (GPi), subthalamic, and subthalamic nucleus (STN) DBS improved both tremor and dystonic symptoms; however, data were limited. A few studies have reported better tremor and dystonia outcomes with combinations of different targets. Concerning adverse effects, gait/balance disorders, and ataxia seemed to be more common among patients treated with thalamic or subthalamic DBS, whereas parkinsonian adverse effects were observed only in patients treated with subthalamic or GPi DBS. Comparative benefits and limitations of these targets remain unclear because of the lack of randomized controlled trials. In conclusion, DBS of these targets may improve tremor with a variable effect on dystonia with different adverse effect profiles. The shortcomings in the literature include long-term motor outcomes, quality of life outcomes, optimal DBS targeting, and DBS programming strategy.
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Affiliation(s)
- Takashi Tsuboi
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA; Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Ka Loong Kelvin Au
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Wissam Deeb
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kelly D Foote
- Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
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