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Schoeberl F, Dowsett J, Pradhan C, Grabova D, Köhler A, Taylor P, Zwergal A. TMS of the left primary motor cortex improves tremor intensity and postural control in primary orthostatic tremor. J Neurol 2024; 271:2938-2947. [PMID: 38625401 PMCID: PMC11136716 DOI: 10.1007/s00415-024-12376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024]
Abstract
A ponto-cerebello-thalamo-cortical network is the pathophysiological correlate of primary orthostatic tremor. Affected patients often do not respond satisfactorily to pharmacological treatment. Consequently, the objective of the current study was to examine the effects of a non-invasive neuromodulation by theta burst repetitive transcranial magnetic stimulation (rTMS) of the left primary motor cortex (M1) and dorsal medial frontal cortex (dMFC) on tremor frequency, intensity, sway path and subjective postural stability in primary orthostatic tremor. In a cross-over design, eight patients (mean age 70.2 ± 5.4 years, 4 female) with a primary orthostatic tremor received either rTMS of the left M1 leg area or the dMFC at the first study session, followed by the other condition (dMFC or M1 respectively) at the second study session 30 days later. Tremor frequency and intensity were quantified by surface electromyography of lower leg muscles and total sway path by posturography (foam rubber with eyes open) before and after each rTMS session. Patients subjectively rated postural stability on the posturography platform following each rTMS treatment. We found that tremor frequency did not change significantly with M1- or dMFC-stimulation. However, tremor intensity was lower after M1- but not dMFC-stimulation (p = 0.033/ p = 0.339). The sway path decreased markedly after M1-stimulation (p = 0.0005) and dMFC-stimulation (p = 0.023) compared to baseline. Accordingly, patients indicated a better subjective feeling of postural stability both with M1-rTMS (p = 0.007) and dMFC-rTMS (p = 0.01). In conclusion, non-invasive neuromodulation particularly of the M1 area can improve postural control and tremor intensity in primary orthostatic tremor by interference with the tremor network.
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Affiliation(s)
- Florian Schoeberl
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - James Dowsett
- Division of Psychology, University of Stirling, Stirling, UK
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Denis Grabova
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Angelina Köhler
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Paul Taylor
- Faculty of Philosophy, Philosophy of Science and the Study of Religion, LMU Munich, Munich, Germany
| | - Andreas Zwergal
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany.
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Babeliowsky WA, Bot M, Potters WV, van den Munckhof P, Blok ER, de Bie RM, Schuurman R, van Rootselaar A. Deep Brain Stimulation for Orthostatic Tremor: An Observational Study. Mov Disord Clin Pract 2024; 11:676-685. [PMID: 38586984 PMCID: PMC11145120 DOI: 10.1002/mdc3.14035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 02/09/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Primary orthostatic tremor (OT) can affect patients' life. Treatment of OT with deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (Vim) is described in a limited number of patients. The Vim and posterior subthalamic area (PSA) can be targeted in a single trajectory, allowing both stimulation of the Vim and/or dentatorubrothalamic tract (DRT). In essential tremor this is currently often used with positive effects. OBJECTIVE To evaluate the efficacy of Vim/DRT-DBS in OT-patients, based on standing time and Quality of Life (QoL), also on the long-term. Furthermore, to relate stimulation of the Vim and DRT, medial lemniscus (ML) and pyramidal tract (PT) to beneficial clinical and side-effects. METHODS Nine severely affected OT-patients received bilateral Vim/DRT-DBS. Primary outcome measure was standing time; secondary measures included self-reported measures, neurophysiological measures, structural analyses, surgical complications, stimulation-induced side-effects, and QoL up to 56 months. Stimulation of volume of tissue activated (VTA) were related to outcome measures. RESULTS Average maximum standing time increased from 41.0 s ± 51.0 s to 109.3 s ± 65.0 s after 18 months, with improvements measured in seven of nine patients. VTA (n = 7) overlapped with the DRT in six patients and with the ML and/or PT in six patients. All patients experienced side-effects and QoL worsened during the first year after surgery, which improved again during long-term follow-up, although remaining below age-related normal values. Most patients reported a positive effect of DBS. CONCLUSION Vim/DRT-DBS improved standing time in patients with severe OT. Observed side-effects are possibly related to stimulation of the ML and PT.
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Affiliation(s)
- Wietske A. Babeliowsky
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Maarten Bot
- NeurosurgeryAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Wouter V. Potters
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | | | - Edwin R. Blok
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Rob M.A. de Bie
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
- Amsterdam NeuroscienceNeurodegenerationAmsterdamThe Netherlands
| | - Rick Schuurman
- NeurosurgeryAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Anne‐Fleur van Rootselaar
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
- Amsterdam NeuroscienceNeurodegenerationAmsterdamThe Netherlands
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Boogers A, Billet A, Vandenberghe W, Nuttin B, Theys T, Mc Laughlin M, De Vloo P. Deep brain stimulation and spinal cord stimulation for orthostatic tremor: A systematic review. Parkinsonism Relat Disord 2022; 104:115-120. [PMID: 36243552 DOI: 10.1016/j.parkreldis.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/24/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Orthostatic tremor is a rare and debilitating movement disorder. Its first-line treatment is pharmacological. For pharmaco-refractory patients, surgical treatment options such as deep brain stimulation (DBS) and spinal cord stimulation (SCS) have been investigated recently. OBJECTIVES We conducted a systematic review of all published outcome and safety data on DBS and SCS for orthostatic tremor patients. METHODS We searched Pubmed and Embase for studies describing orthostatic tremor patients treated with DBS or SCS. We collected all available outcome and safety data and our primary endpoint was the change in unsupported stance duration 1 year postoperatively (±6 months). RESULTS We included 15 studies, reporting on 32 orthostatic tremor patients who underwent DBS, 4 patients SCS and 2 both. The ventral intermediate nucleus and the zona incerta were targeted in 25/34 and 9/34 DBS cases, respectively. The median stance time at 1 year follow-up was 240 s compared to 30 s pre-operatively (p < 0.001). Stimulation-induced side effects occurred in the majority of patients, but were often transient. Bilateral stimulation appeared more effective than unilateral and stimulation settings were comparable to thalamic DBS for essential tremor. There were insufficient data available to draw meaningful conclusions on the long-term effects of DBS. Due to insufficient data, no conclusions could be drawn on the effects of SCS on orthostatic tremor. CONCLUSION DBS may be effective to increase stance time in orthostatic tremor patients in the first year, but further research is necessary to evaluate the long-term effects and the role of spinal cord stimulation.
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Affiliation(s)
- Alexandra Boogers
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Alexine Billet
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Parkinson Research, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Tom Theys
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Myles Mc Laughlin
- Research Group Experimental ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Rare tremors and tremors occurring in other neurological disorders. J Neurol Sci 2022; 435:120200. [DOI: 10.1016/j.jns.2022.120200] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 12/21/2022]
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Iorio-Morin C, Fomenko A, Kalia SK. Deep-Brain Stimulation for Essential Tremor and Other Tremor Syndromes: A Narrative Review of Current Targets and Clinical Outcomes. Brain Sci 2020; 10:E925. [PMID: 33271848 PMCID: PMC7761254 DOI: 10.3390/brainsci10120925] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023] Open
Abstract
Tremor is a prevalent symptom associated with multiple conditions, including essential tremor (ET), Parkinson's disease (PD), multiple sclerosis (MS), stroke and trauma. The surgical management of tremor evolved from stereotactic lesions to deep-brain stimulation (DBS), which allowed safe and reversible interference with specific neural networks. This paper reviews the current literature on DBS for tremor, starting with a detailed discussion of current tremor targets (ventral intermediate nucleus of the thalamus (Vim), prelemniscal radiations (Raprl), caudal zona incerta (Zi), thalamus (Vo) and subthalamic nucleus (STN)) and continuing with a discussion of results obtained when performing DBS in the various aforementioned tremor syndromes. Future directions for DBS research are then briefly discussed.
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Affiliation(s)
- Christian Iorio-Morin
- Christian Iorio-Morin, Division of Neurosurgery, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Anton Fomenko
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
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Hewitt AL, Klassen BT, Lee KH, Van Gompel JJ, Hassan A. Deep brain stimulation for orthostatic tremor: A single-center case series. Neurol Clin Pract 2020; 10:324-332. [PMID: 32983612 DOI: 10.1212/cpj.0000000000000730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/13/2019] [Indexed: 11/15/2022]
Abstract
Background Orthostatic tremor (OT) is a high-frequency weight-bearing tremor of the legs and trunk associated with progressive disability and is often refractory to medications. Case reports suggest that thalamic deep brain stimulation (DBS) is effective. We report 5 female patients with medication-refractory OT who underwent bilateral thalamic DBS at the Mayo Clinic and assess factors associated with a successful DBS outcome. Methods Demographic, clinical, electrophysiology, and DBS data were abstracted. Outcomes were change in tremor-onset latency, standing time, standing ADLs, and patient and clinician global impression of change (PGIC; CGIC). Results All 5 patients had improved standing time (72 vs 408 seconds, p ≤ 0.001) and improved standing ADLs after surgery, without change in tremor-onset latency (16 vs 75 seconds, p = 0.14). Maximal benefit was reached up to 3 years after surgery and sustained for up to 6 years. CGIC was "much improved" in all; PGIC was "much improved" in 4 and "minimally improved" in 1. There were no major complications. Postoperative electrophysiology (n = 1) showed lower tremor amplitude and slower tremor ramp-up on vs off stimulation. Conclusions Bilateral thalamic DBS improved OT symptoms with benefit lasting up to 6 years. A modest increase in standing time of several minutes was associated with meaningful improvement in standing ADLs. Microlesional effect and bilateral stimulation are likely favorable features, while baseline standing time of several minutes may be unfavorable. These findings may inform clinician and patient counseling and require confirmation in larger studies.
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Affiliation(s)
- Angela L Hewitt
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Bryan T Klassen
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Kendall H Lee
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Jamie J Van Gompel
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Anhar Hassan
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
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Katlowitz K, Ko M, Mogilner AY, Pourfar M. Effect of deep brain simulation on arm, leg, and chin tremor in Parkinson disease. J Neurosurg 2019; 131:1514-1519. [PMID: 30544332 DOI: 10.3171/2018.7.jns18784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The efficacy of deep brain stimulation (DBS) of the subthalamic nucleus (STN) in the treatment of Parkinson disease (PD)-related tremor has been well established. However, the relative impact on arm, leg, and chin tremor has been less clearly elucidated. The authors evaluated the distribution of tremors in a PD cohort undergoing STN DBS and sought to evaluate the differential impact of DBS as a function of tremor location. METHODS A retrospective study of patients with PD with tremor who underwent DBS surgery between 2012 and 2016 was performed to evaluate the impact of STN stimulation on overall and regional tremor scores. RESULTS Across 66 patients the authors found an average of 78% overall reduction in tremor after 6 months. In this cohort, the authors found that tremor reduction was somewhat better for arm than for leg tremors, especially in instances of higher preoperative tremor (84% vs 71% reduction, respectively, for initial tremor scores ≥ 2). No significant difference in response was found between patients with medication-responsive versus medication-nonresponsive tremors. CONCLUSIONS The authors found that although DBS improved tremor in all regions, the improvement was not uniform between chin, arm, and leg-even within the same patient. The reasons behind these differing responses are speculative but suggest that STN DBS may more reliably reduce arm tremors than leg tremors.
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Gilmore G, Murgai A, Nazer A, Parrent A, Jog M. Zona incerta deep-brain stimulation in orthostatic tremor: efficacy and mechanism of improvement. J Neurol 2019; 266:2829-2837. [DOI: 10.1007/s00415-019-09505-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/03/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022]
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Evidente VGH, Baker ZJ, Evidente MH, Garrett R, Lambert M, Ponce FA. Orthostatic Tremor is Responsive to Bilateral Thalamic Deep Brain Stimulation: Report of Two Cases Performed Asleep. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018; 8:566. [PMID: 30191085 PMCID: PMC6125736 DOI: 10.7916/d8ks882g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/09/2018] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT) is a hyperkinetic movement disorder characterized by rapid tremor in the lower extremities or trunk upon standing. Case Report We report two patients presenting with OT, whose symptoms improved markedly following asleep bilateral thalamic deep brain stimulation (DBS) surgery. Discussion Medically refractory OT can respond favorably to asleep bilateral DBS surgery similar to awake surgery, and may have the advantages of less psychological trauma to the patient, shorter procedure times, and less exposure to anesthesia.
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Affiliation(s)
| | | | | | - Robin Garrett
- Movement Disorders Center of Arizona, Scottsdale, AZ, USA
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Deep brain stimulation in uncommon tremor disorders: indications, targets, and programming. J Neurol 2018; 265:2473-2493. [PMID: 29511865 DOI: 10.1007/s00415-018-8823-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In uncommon tremor disorders, clinical efficacy and optimal anatomical targets for deep brain stimulation (DBS) remain inadequately studied and insufficiently quantified. METHODS We performed a systematic review of PubMed.gov and ClinicalTrials.gov. Relevant articles were identified using the following keywords: "tremor", "Holmes tremor", "orthostatic tremor", "multiple sclerosis", "multiple sclerosis tremor", "neuropathy", "neuropathic tremor", "fragile X-associated tremor/ataxia syndrome", and "fragile X." RESULTS We identified a total of 263 cases treated with DBS for uncommon tremor disorders. Of these, 44 had Holmes tremor (HT), 18 orthostatic tremor (OT), 177 multiple sclerosis (MS)-associated tremor, 14 neuropathy-associated tremor, and 10 fragile X-associated tremor/ataxia syndrome (FXTAS). DBS resulted in favorable, albeit partial, clinical improvements in HT cases receiving Vim-DBS alone or in combination with additional targets. A sustained improvement was reported in OT cases treated with bilateral Vim-DBS, while the two cases treated with unilateral Vim-DBS demonstrated only a transient effect. MS-associated tremor responded to dual-target Vim-/VO-DBS, but the inability to account for the progression of MS-associated disability impeded the assessment of its long-term clinical efficacy. Neuropathy-associated tremor substantially improved with Vim-DBS. In FXTAS patients, while Vim-DBS was effective in improving tremor, equivocal results were observed in those with ataxia. CONCLUSIONS DBS of select targets may represent an effective therapeutic strategy for uncommon tremor disorders, although the level of evidence is currently in its incipient form and based on single cases or limited case series. An international registry is, therefore, warranted to clarify selection criteria, long-term results, and optimal surgical targets.
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Abstract
Tremor is a phenomenon observed in a broad spectrum of diseases with different pathophysiologies. While patients with tremor may not complain in the clinic of symptoms of imbalance, gait difficulties, or falls, laboratory research studies using quantitative analysis of gait and posture and neurophysiologic techniques have demonstrated impaired gait and balance across a variety of tremor etiologies. These findings have been supported by careful epidemiologic studies assessing symptoms of imbalance. Imaging and neurophysiologic studies have identified cerebellar networks as important mediators of tremor, and therefore a likely common site of dysfunction to explain the phenomenologic overlap between impaired postural and gait control with tremor. Further understanding of these mechanisms and networks is of crucial importance in the development of new treatments, particularly surgical or minimally invasive lesional therapies.
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Affiliation(s)
- Hugo Morales-Briceño
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Alessandro F Fois
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Lehn AC, O'Gorman C, Olson S, Salari M. Thalamic Ventral Intermediate Nucleus Deep Brain Stimulation for Orthostatic Tremor. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:479. [PMID: 28983421 PMCID: PMC5628322 DOI: 10.7916/d8280jhr] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/28/2017] [Indexed: 12/02/2022]
Abstract
Background Orthostatic tremor (OT) was first described in 1977. It is characterized by rapid tremor of 13–18 Hz and can be recorded in the lower limbs and trunk muscles. OT remains difficult to treat, although some success has been reported with deep brain stimulation (DBS). Case Report We report a 68‐year‐old male with OT who did not improve significantly after bilateral thalamic stimulation. Discussion Although some patients were described who improved after DBS surgery, more information is needed about the effect of these treatment modalities on OT, ideally in the form of randomized trial data.
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Affiliation(s)
- Alexander C Lehn
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Cullen O'Gorman
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,Griffith University, Gold Coast, Australia
| | - Sarah Olson
- Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Mehri Salari
- Department of Neurology, School of medicine, Qom University of Medical Science, Qom, Iran
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Treatment of the ventral intermediate nucleus for medically refractory tremor: A cost-analysis of stereotactic radiosurgery versus deep brain stimulation. Radiother Oncol 2017; 125:136-139. [PMID: 28818305 DOI: 10.1016/j.radonc.2017.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Medically refractory tremor treatment has evolved over the past half-century from intraoperative thalamotomy to deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM). Within the past 15years, unilateral radiosurgical VIM thalamotomy has emerged as a comparably efficacious treatment modality. METHODS An extensive literature search of VIM DBS series was performed; the total cost of VIM DBS was calculated from hospitals geographically representative of the entire United States using current procedural terminology and work relative value unit (RVU) codes. The 2016 Medicare Ambulatory Payment Classification for stereotactic radiosurgery (SRS) was added to the work RVU to determine the total cost of VIM SRS for both Gamma Knife and linear accelerator SRS. Cost estimates assumed that VIM DBS was performed without intraoperative microelectrode recording. RESULT The mean unilateral VIM DBS cost was $17,932.41 per patient. For SRS VIM, the total costs for Gamma Knife ($10,811.77) and linear accelerator ($10,726.40) were 40% less expensive than for unilateral VIM DBS. CONCLUSION Radiosurgery of the VIM is 40% less expensive than unilateral VIM DBS in treatment of medically refractory tremor, regardless of radiosurgical modality. This finding argues for increased radiation oncology involvement in the management of medically refractory tremor patients.
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Merola A, Fasano A, Hassan A, Ostrem JL, Contarino MF, Lyons M, Krauss JK, Wolf ME, Klassen BT, van Rootselaar AF, Regidor I, Duker AP, Ondo W, Guridi J, Volkmann J, Wagle Shukla A, Mandybur GT, Okun MS, Witt K, Starr PA, Deuschl G, Espay AJ. Thalamic deep brain stimulation for orthostatic tremor: A multicenter international registry. Mov Disord 2017. [PMID: 28631862 DOI: 10.1002/mds.27082] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - Alfonso Fasano
- Division of Neurology, Movement disorders center, University of Toronto Canada Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Division of Neurology; University of Toronto; Toronto Ontario Canada
- Krembil Research Institute; Toronto Ontario Canada
| | - Anhar Hassan
- Department of Neurology; Mayo Clinic; Rochester Minnesota USA
| | - Jill L. Ostrem
- UCSF Movement Disorders and Neuromodulation Center, Department of Neurology; University of California San Francisco; San Francisco California USA
| | - Maria Fiorella Contarino
- Department of Neurology; Academic Medical Center; Amsterdam The Netherlands
- Department of Neurology; Leiden University Medical Center; Leiden The Netherlands
- Department of Neurology; Haga Teaching Hospital; The Hague The Netherlands
| | - Mark Lyons
- Department of Neurosurgery; Mayo Clinic; Phoenix Arizona USA
| | - Joachim K. Krauss
- Department of Neurosurgery; Medical School Hannover, MHH; Hannover Germany
| | - Marc E. Wolf
- Department of Neurology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim; University of Heidelberg; Mannheim Germany
| | | | | | - Ignacio Regidor
- Functional Neurosurgery Unit; Hospital Universitario Ramón y Cajal; Madrid Spain
| | - Andrew P. Duker
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - William Ondo
- Methodist Neurological Institute; Houston Texas USA
| | - Jorge Guridi
- Neurosurgical Department, Clinica Universidad de Navarra; Navarra Spain
| | - Jens Volkmann
- Department of Neurology; University Hospital Würzburg; Würzburg Germany
| | - Aparna Wagle Shukla
- Department of Neurology, Center for Movement Disorders and Neurorestoration; McKnight Brain Institute; Gainesville Florida USA
| | - George T. Mandybur
- Department of Neurosurgery; University of Cincinnati College of Medicine. Mayfield Clinic- Neurosurgeon; Cincinnati Ohio USA
| | - Michael S. Okun
- Department of Neurology, Center for Movement Disorders and Neurorestoration; McKnight Brain Institute; Gainesville Florida USA
| | - Karsten Witt
- Department of Neurology; University Medical Center Schleswig-Holstein, Christian-Albrechts University; Kiel Germany
- Dept. of Neurology; School of Medicine and Health Sciences - European Medical School, University Oldenburg; Oldenburg Germany
| | - Philip A. Starr
- UCSF Department of Neurological Surgery; University of California San Francisco; San Francisco California USA
| | - Günther Deuschl
- Department of Neurology; University Medical Center Schleswig-Holstein, Christian-Albrechts University; Kiel Germany
| | - Alberto J. Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
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Schöberl F, Feil K, Xiong G, Bartenstein P, la Fougére C, Jahn K, Brandt T, Strupp M, Dieterich M, Zwergal A. Pathological ponto-cerebello-thalamo-cortical activations in primary orthostatic tremor during lying and stance. Brain 2017; 140:83-97. [PMID: 28031220 DOI: 10.1093/brain/aww268] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/25/2016] [Accepted: 09/07/2016] [Indexed: 11/14/2022] Open
Abstract
Primary orthostatic tremor is a rare neurological disease characterized mainly by a high frequency tremor of the legs while standing. The aim of this study was to identify the common core structures of the oscillatory circuit in orthostatic tremor and how it is modulated by changes of body position. Ten patients with orthostatic tremor and 10 healthy age-matched control subjects underwent a standardized neurological and neuro-ophthalmological examination including electromyographic and posturographic recordings. Task-dependent changes of cerebral glucose metabolism during lying and standing were measured in all subjects by sequential 18F-fluorodeoxyglucose-positron emission tomography on separate days. Results were compared between groups and conditions. All the orthostatic tremor patients, but no control subject, showed the characteristic 13-18 Hz tremor in coherent muscles during standing, which ceased in the supine position. While lying, patients had a significantly increased regional cerebral glucose metabolism in the pontine tegmentum, the posterior cerebellum (including the dentate nuclei), the ventral intermediate and ventral posterolateral nucleus of the thalamus, and the primary motor cortex bilaterally compared to controls. Similar glucose metabolism changes occurred with clinical manifestation of the tremor during standing. The glucose metabolism was relatively decreased in mesiofrontal cortical areas (i.e. the medial prefrontal cortex, supplementary motor area and anterior cingulate cortex) and the bilateral anterior insula in orthostatic tremor patients while lying and standing. The mesiofrontal hypometabolism correlated with increased body sway in posturography. This study confirms and further elucidates ponto-cerebello-thalamo-primary motor cortical activations underlying primary orthostatic tremor, which presented consistently in a group of patients. Compared to other tremor disorders one characteristic feature in orthostatic tremor seems to be the involvement of the pontine tegmentum in the pathophysiology of tremor generation. High frequency oscillatory properties of pontine tegmental neurons have been reported in pathological oscillatory eye movements. It is remarkable that the characteristic activation and deactivation pattern in orthostatic tremor is already present in the supine position without tremor presentation. Multilevel changes of neuronal excitability during upright stance may trigger activation of the orthostatic tremor network. Based on the functional imaging data described in this study, it is hypothesized that a mesiofrontal deactivation is another characteristic feature of orthostatic tremor and plays a pivotal role in development of postural unsteadiness during prolonged standing.
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Affiliation(s)
- Florian Schöberl
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Katharina Feil
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Guoming Xiong
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Peter Bartenstein
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,3 Department of Nuclear Medicine, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,4 Munich Cluster of Systems Neurology, SyNergy, Marchioninistr. 15, 81377 Munich, Germany
| | - Christian la Fougére
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,5 Department of Nuclear Medicine, Eberhard Karls University, Röntgenweg 11, 72076 Tübingen, Germany
| | - Klaus Jahn
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,6 Neurology, Schön Klinik Bad Aibling, Kolbermoorer Str. 72, 83043 Bad Aibling, Germany
| | - Thomas Brandt
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,7 Clinical Neurosciences, Ludwig-Maximilians-Unversity, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael Strupp
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Marianne Dieterich
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,4 Munich Cluster of Systems Neurology, SyNergy, Marchioninistr. 15, 81377 Munich, Germany
| | - Andreas Zwergal
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany .,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
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Hassan A, van Gerpen JA. Orthostatic Tremor and Orthostatic Myoclonus: Weight-bearing Hyperkinetic Disorders: A Systematic Review, New Insights, and Unresolved Questions. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 6:417. [PMID: 28105385 PMCID: PMC5233784 DOI: 10.7916/d84x584k] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/25/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Orthostatic tremor (OT) and orthostatic myoclonus (OM) are weight-bearing hyperkinetic movement disorders most commonly affecting older people that induce "shaky legs" upon standing. OT is divided into "classical" and "slow" forms based on tremor frequency. In this paper, the first joint review of OT and OM, we review the literature and compare and contrast their demographic, clinical, electrophysiological, neuroimaging, pathophysiological, and treatment characteristics. METHODS A PubMed search up to July 2016 using the phrases "orthostatic tremor," "orthostatic myoclonus," "shaky legs," and "shaky legs syndrome" was performed. RESULTS OT and OM should be suspected in older patients reporting unsteadiness with prolonged standing and/or who exhibit cautious, wide-based gaits. Surface electromyography (SEMG) is necessary to verify the diagnoses. Functional neuroimaging and electrophysiology suggest the generator of classical OT lies within the cerebellothalamocortical network. For OM, and possibly slow OT, the frontal, subcortical cerebrum is the most likely origin. Clonazepam is the most useful medication for classical OT, and levetiracetam for OM, although results are often disappointing. Deep brain stimulation appears promising for classical OT. Rolling walkers reliably improve gait affected by these disorders, as both OT and OM attenuate when weight is transferred from the legs to the arms. DISCUSSION Orthostatic hyperkinesias are likely underdiagnosed, as SEMG is often unavailable in clinical practice, and thus may be more frequent than currently recognized. The shared weight-bearing induction of OT and OM may indicate a common pathophysiology. Further research, including use of animal models, is necessary to better define the prevalence and pathophysiology of OT and OM, in order to improve their treatment, and provide additional insights into basic balance and gait mechanisms.
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Affiliation(s)
- Anhar Hassan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Benito-León J, Domingo-Santos Á. Orthostatic Tremor: An Update on a Rare Entity. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2016; 6:411. [PMID: 27713855 PMCID: PMC5039949 DOI: 10.7916/d81n81bt] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/22/2016] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT) remains among the most intriguing and poorly understood of movement disorders. Compared to Parkinson’s disease or even essential tremor, there are very few articles addressing more basic science issues. In this review, we will discuss the findings of main case series on OT, including data on etiology, pathophysiology, diagnostic approach, treatment strategies, and outcome. Methods Data for this review were identified by searching PUBMED (January 1966 to August 2016) for the terms “orthostatic tremor” or “shaky leg syndrome,” which yielded 219 entries. We did not exclude papers on the basis of language, country, or publication date. The electronic database searches were supplemented by articles in the authors’ files that pertained to this topic. Results Owing to its rarity, the current understanding of OT is limited and is mostly based on small case series or case reports. Despite this, a growing body of evidence indicates that OT might be a progressive condition that is clinically heterogeneous (primary vs. secondary cases) with a broader spectrum of clinical features, mainly cerebellar signs, and possible cognitive impairment and personality disturbances. Along with this, advanced neuroimaging techniques are now demonstrating distinct anatomical and functional changes, some of which are consistent with neuronal loss. Discussion OT might be a family of diseases, unified by the presence of leg tremor, but further characterized by etiological and clinical heterogeneity. More work is needed to understand the pathogenesis of this condition.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain
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Abstract
Introduction: Deep brain stimulation (DBS) has become a standard therapy for the treatment of select cases of medication refractory essential tremor and Parkinson’s disease however the effectiveness and long-term outcomes of DBS in other uncommon and complex tremor syndromes has not been well established. Traditionally, the ventralis intermedius nucleus (VIM) of the thalamus has been considered the main target for medically intractable tremors; however alternative brain regions and improvements in stereotactic techniques and hardware may soon change the horizon for treatment of complex tremors. Areas covered: In this article, we conducted a PubMed search using different combinations between the terms ‘Uncommon tremors’, ‘Dystonic tremor’, ‘Holmes tremor’ ‘Midbrain tremor’, ‘Rubral tremor’, ‘Cerebellar tremor’, ‘outflow tremor’, ‘Multiple Sclerosis tremor’, ‘Post-traumatic tremor’, ‘Neuropathic tremor’, and ‘Deep Brain Stimulation/DBS’. Additionally, we examined and summarized the current state of evolving interventions for treatment of complex tremor syndromes. Expertcommentary: Recently reported interventions for rare tremors include stimulation of the posterior subthalamic area, globus pallidus internus, ventralis oralis anterior/posterior thalamic subnuclei, and the use of dual lead stimulation in one or more of these targets. Treatment should be individualized and dictated by tremor phenomenology and associated clinical features.
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Affiliation(s)
| | - Michael S Okun
- b Department of Neurology , University of Florida Center for Movement Disorders and Neurorestoration , Gainesville FL , USA
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