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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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Paoli D, Mills R, Brechany U, Pavese N, Nicholson C. DBS in tremor with dystonia: VIM, GPi or both? A review of the literature and considerations from a single-center experience. J Neurol 2023; 270:2217-2229. [PMID: 36680569 PMCID: PMC10025201 DOI: 10.1007/s00415-023-11569-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) is an established treatment for dystonia and tremor. However, there is no consensus about the best surgical targeting strategy in patients with concomitant tremor and dystonia. Both the thalamic ventral intermediate nucleus (VIM) and the globus pallidus pars interna (GPi) have been proposed as targets. Few cases using them together in a double-target approach have also been reported. METHODS We reviewed the literature on this topic, summarizing results of different target choices. Additionally, we retrospectively report a case series of nine patients with sporadic dystonia and severe tremor treated with a double-target strategy at our center. Outcome measures were the Burke-Fahn-Marsden Dystonia Rating Scale (BFM) and Eq-5d scale. RESULTS In published studies of patients with dystonia and tremor, VIM-DBS is highly effective on tremor but raise some concerns about dystonia's control, while GPi-DBS is more effective on dystonia but does not always relieve tremor. GPi + VIM-DBS shows good efficacy but is rarely reported and reserved for selected patients. In our patients, the double-target strategy obtained a significant and durable improvement in tremor, dystonia, and quality of life. Additionally, compared with a cohort of patients with tremor treated with VIM-DBS only, significantly lower frequency and intensity of VIM stimulation were required to control tremor. CONCLUSION Our findings and published evidence seem to support the double-targeting approach as a safe and effective option in selected patients with tremor-dominant dystonia. This strategy appears to provide a more extensive control of either dystonia or tremor and may have a potential for limiting stimulation-related side effects.
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Affiliation(s)
- Davide Paoli
- Clinical Ageing Research Unit, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Ospedale Santa Chiara, 56126, Pisa, Italy
| | - Russell Mills
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Una Brechany
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Nicola Pavese
- Clinical Ageing Research Unit, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK.
- Newcastle Magnetic Resonance Centre and Positron Emission Tomography Centre - Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK.
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark.
| | - Claire Nicholson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
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Gupta N, Pandey S. Rest tremor in dystonia: epidemiology, differential diagnosis, and pathophysiology. Neurol Sci 2020; 41:2377-2388. [PMID: 32328831 DOI: 10.1007/s10072-020-04402-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The most common type of tremor reported in dystonia patients is postural and kinetic. There is uncertainty regarding the prevalence of rest tremor in dystonia. OBJECTIVE This review focuses on the clinical and neurophysiological features of rest tremor in dystonia, its differential diagnosis, and methods to distinguish it from other rest tremor syndromes. METHODS A PubMed search was done, and the available literature identified. Bibliography of the available literature was reviewed for relevant references. RESULTS Rest tremor in dystonia has been reported with a variable frequency of 1.81-12.05%. The most common body distribution is arm, and it tends to be asymmetric. Most of the affected patients have multifocal and segmental dystonia. Rest tremor is a late-onset phenomenon associated with severe and spreading dystonia. Clinically, it is difficult to distinguish rest tremor in dystonia from other rest tremor syndromes based on tremor characteristics; however, other neurological signs can provide clues to differentiate these syndromes. Surface electromyography and other neurophysiological tests can help differentiate the various rest tremor syndromes. CONCLUSION Rest tremor in dystonia can be differentiated from other rest tremor syndromes based on neurophysiological techniques. There is some evidence to suggest that SWEDDs could be a form of dystonic tremor, but further studies are required to clarify this diagnostic dilemma. Data regarding the treatment of rest tremor in dystonia are virtually nonexistent, and there is an urgent need for prospective studies focusing its medical management and to know the surgical targets.
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Affiliation(s)
- Navnika Gupta
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, Academic Block, Room No. 503, New Delhi, 110002, India.,University of Nebraska Medical Center, Omaha, NE, USA
| | - Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, Academic Block, Room No. 503, New Delhi, 110002, India.
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Neudorfer C, Maarouf M. Neuroanatomical background and functional considerations for stereotactic interventions in the H fields of Forel. Brain Struct Funct 2017; 223:17-30. [DOI: 10.1007/s00429-017-1570-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 11/13/2017] [Indexed: 11/29/2022]
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Ramirez-Zamora A, Kaszuba B, Gee L, Prusik J, Molho E, Wilock M, Shin D, Pilitsis JG. Clinical outcome and intraoperative neurophysiology for focal limb dystonic tremor without generalized dystonia treated with deep brain stimulation. Clin Neurol Neurosurg 2016; 150:169-176. [DOI: 10.1016/j.clineuro.2016.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/03/2016] [Accepted: 06/05/2016] [Indexed: 01/14/2023]
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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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Abstract
Tremor is one of the clinical manifestations of dystonia; however, there are no specific therapeutic trials evaluating the efficacy of treatments for dystonic tremor (DT), tremor associated with dystonia or primary writing tremor (PWT). We systematically reviewed the literature available up to July 2013 on the treatment of these tremors and retrieved the data of 487 patients published in 43 papers detailing the effects of given interventions on tremor severity. Treatment outcome was highly variable, depending on the specific type of intervention and tremor distribution. No specifically designed studies were available for the treatment of tremor associated with dystonia. As for the other tremors, drug efficacy was generally disappointing and a moderate effect was only found with anticholinergics, tetrabenazine, clonazepam, β-blockers and primidone; levodopa was only efficacious on tremor due to dopa-responsive dystonia. The largest amount of data was available for botulinum toxin injections, which provided a marked improvement, particularly for the management of axial tremors (head or vocal cords). In refractory DTs, deep brain stimulation of several targets was attempted. Deep brain stimulation of globus pallidus internus, thalamus or subthalamic area led to a marked improvement of dystonic axial or appendicular tremors in most cases refractory to other treatments. Few other non-invasive treatments, for example, orthotic device in PWT, have been used with anecdotal success. In conclusion, considering the lack of good-quality studies, future randomised controlled trials are needed. In absence of evidence-based guidelines, we propose an algorithm for the treatment of DT based on currently available data.
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Affiliation(s)
- Alfonso Fasano
- Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Francesco Bove
- Department of Neurology, Istituto di Neurologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Anthony E Lang
- Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada Department of Neurology, The Edmond J. Safra Program in Parkinson's Disease, Toronto, Ontario, Canada
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Buhmann C, Moll CKE, Zittel S, Münchau A, Engel AK, Hamel W. Deep brain stimulation of the ventrolateral thalamic base and posterior subthalamic area in dystonic head tremor. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 117:67-72. [PMID: 23652659 DOI: 10.1007/978-3-7091-1482-7_11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Dystonic head tremor (DHT) is characterized by head tremor associated with cervical dystonia (CD). Deep brain stimulation (DBS) can be considered when local treatment with botulinum toxin or oral medication has failed. However, there is lack of data regarding the optimal target structure for surgery in DHT.DBS of the ventrolateral (VL) thalamus is an established treatment option for medically refractory tremor. Tremor suppression is described as being most effective when stimulating at the inferior thalamic base and within the posterior subthalamic area (PSA). Moreover, there is surgical evidence from the pre-DBS era that both lesions and high-frequency stimulation of the PSA improve CD. Based on these observations, we performed DBS in three patients with DHT, placing the proximal contacts of the electrodes into the inferior base of VL thalamic nuclei and the distal contacts into the adjacent PSA. Chronic stimulation improved not only head tremor but also CD. These findings suggest that DBS at the base of VL thalamus and the adjacent PSA should undergo further investigation as a potential target for patients with DHT.
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Affiliation(s)
- Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany,
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Nowak K, Mix E, Gimsa J, Strauss U, Sriperumbudur KK, Benecke R, Gimsa U. Optimizing a rodent model of Parkinson's disease for exploring the effects and mechanisms of deep brain stimulation. PARKINSONS DISEASE 2011; 2011:414682. [PMID: 21603182 PMCID: PMC3096058 DOI: 10.4061/2011/414682] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 01/28/2011] [Indexed: 11/20/2022]
Abstract
Deep brain stimulation (DBS) has become a treatment for a growing number of neurological and psychiatric disorders, especially for therapy-refractory Parkinson's disease (PD). However, not all of the symptoms of PD are sufficiently improved in all patients, and side effects may occur. Further progress depends on a deeper insight into the mechanisms of action of DBS in the context of disturbed brain circuits. For this, optimized animal models have to be developed. We review not only charge transfer mechanisms at the electrode/tissue interface and strategies to increase the stimulation's energy-efficiency but also the electrochemical, electrophysiological, biochemical and functional effects of DBS. We introduce a hemi-Parkinsonian rat model for long-term experiments with chronically instrumented rats carrying a backpack stimulator and implanted platinum/iridium electrodes. This model is suitable for (1) elucidating the electrochemical processes at the electrode/tissue interface, (2) analyzing the molecular, cellular and behavioral stimulation effects, (3) testing new target regions for DBS, (4) screening for potential neuroprotective DBS effects, and (5) improving the efficacy and safety of the method. An outlook is given on further developments of experimental DBS, including the use of transgenic animals and the testing of closed-loop systems for the direct on-demand application of electric stimulation.
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Affiliation(s)
- Karl Nowak
- Department of Neurology, University of Rostock, Gehlsheimer Straße 20, 18147 Rostock, Germany
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