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Deep brain stimulation of the globus pallidus internus or ventralis intermedius nucleus of thalamus for Holmes tremor.
Neurosurg Rev. 2015 Oct; 38(4):753-63.NR

Abstract

Holmes tremor (HT) is a difficult-to-treat, very disabling symptomatic condition which characteristically appears weeks to years after a brain lesion. It features a unique combination of rest, action, and postural tremors. Pharmacotherapy is mostly not effective. Chronic deep brain stimulation (DBS) of ventralis intermedius nucleus (Vim) of thalamus has been described as being the best surgical approach in singular case series; various authors observe, however, cases with partial responses only; therefore, alternatives are still needed. We report ten patients with HT unresponsive to best medical therapy who underwent DBS in our center from March 2002 to June 2012. Based in our previous experience dealing with cases of unsatisfactory Vim intraoperative tremor control and in order to optimize surgical results, presurgical target planning included two Nuclei: Vim and posteroventral Globus pallidus internus (GPi) (Espinoza et al. 2010; Espinoza et al. Stereotact Funct Neurosurg 90(suppl 1):1-202, p 61, 2012). Definitive chosen target was decided after single-cell microelectrode recording, intraoperative test stimulation, thresholds for stimulation-induced adverse effects and best clinical response compared to baseline status. Fahn-Tolosa-Marin tremor rating scale (FTM-TRS) was used to evaluate outcome. The electrode was implanted in the nucleus with the best tremor suppression achievement; on the other hand, GPi DBS was initially decided if one of the following conditions was present: (a) If Vim nucleus anatomy was grossly altered; (b) when intraoperative tremor control was unsatisfactory despite Vim high-intensity stimulation; or (c) if unaffordable side effects or even tremor worsening occurred during intraoperative macrostimulation. Seven patients received definitive Gpi DBS implantation, while three patients received Vim DBS. In all observed cases, we observed an improvement on the TRS. In two cases where Vim thalamic anatomy was altered by the pathological insult GPI was planned from the beginning, and same was true in two additional cases where the Gpi nucleus showed major alterations allowing only Vim planning. Over all cases, the average improvement in tremor was of 2.55 points on the TRS or a 64 % increase in measured results; with a minimum of 1 point (25 %) improvement in one case and a maximum of 4 points (100 % improvement) also in one case. All the results were sustained at 2 years follow-up. One case with predominant resting component, implanted in the GPi, achieved the maximum possible tremor reduction (from 4 to 0 points, meaning 100 % tremor reduction); in the nine resting cases, the average reduction was of 3 points (or 75 %). DBS demonstrated in this case series adequate tremor control in 10 patients unresponsive to medical therapy. Presurgical planning of two targets allowed choosing best optimal response. Gpi stimulation could be considered as an alternative target for cases in which thalamic anatomy is considerably altered or Vim intraoperative stimulation does not produce satisfactory results.

Authors+Show Affiliations

Department of Stereotactic and Functional Neurosurgery, Movement Disorders and Pain Clinic, CIMAD, Carrera 19A N 82-14, Bogotá, Colombia, jairoespinoza@cimad.net.co.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

25990341

Citation

Espinoza Martinez, Jairo Alberto, et al. "Deep Brain Stimulation of the Globus Pallidus Internus or Ventralis Intermedius Nucleus of Thalamus for Holmes Tremor." Neurosurgical Review, vol. 38, no. 4, 2015, pp. 753-63.
Espinoza Martinez JA, Arango GJ, Fonoff ET, et al. Deep brain stimulation of the globus pallidus internus or ventralis intermedius nucleus of thalamus for Holmes tremor. Neurosurg Rev. 2015;38(4):753-63.
Espinoza Martinez, J. A., Arango, G. J., Fonoff, E. T., Reithmeier, T., Escobar, O. A., Furlanetti, L., Alvarez Berastegui, G. R., Fernandes da Silva, F. E., & Contreras Lopez, W. O. (2015). Deep brain stimulation of the globus pallidus internus or ventralis intermedius nucleus of thalamus for Holmes tremor. Neurosurgical Review, 38(4), 753-63. https://doi.org/10.1007/s10143-015-0636-0
Espinoza Martinez JA, et al. Deep Brain Stimulation of the Globus Pallidus Internus or Ventralis Intermedius Nucleus of Thalamus for Holmes Tremor. Neurosurg Rev. 2015;38(4):753-63. PubMed PMID: 25990341.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Deep brain stimulation of the globus pallidus internus or ventralis intermedius nucleus of thalamus for Holmes tremor. AU - Espinoza Martinez,Jairo Alberto, AU - Arango,Gabriel J, AU - Fonoff,Erich Talamoni, AU - Reithmeier,Thomas, AU - Escobar,Oscar Andrés, AU - Furlanetti,Luciano, AU - Alvarez Berastegui,G Rene, AU - Fernandes da Silva,Fabio Eduardo, AU - Contreras Lopez,William Omar, Y1 - 2015/05/20/ PY - 2014/05/07/received PY - 2015/01/19/accepted PY - 2014/10/06/revised PY - 2015/5/21/entrez PY - 2015/5/21/pubmed PY - 2016/6/30/medline SP - 753 EP - 63 JF - Neurosurgical review JO - Neurosurg Rev VL - 38 IS - 4 N2 - Holmes tremor (HT) is a difficult-to-treat, very disabling symptomatic condition which characteristically appears weeks to years after a brain lesion. It features a unique combination of rest, action, and postural tremors. Pharmacotherapy is mostly not effective. Chronic deep brain stimulation (DBS) of ventralis intermedius nucleus (Vim) of thalamus has been described as being the best surgical approach in singular case series; various authors observe, however, cases with partial responses only; therefore, alternatives are still needed. We report ten patients with HT unresponsive to best medical therapy who underwent DBS in our center from March 2002 to June 2012. Based in our previous experience dealing with cases of unsatisfactory Vim intraoperative tremor control and in order to optimize surgical results, presurgical target planning included two Nuclei: Vim and posteroventral Globus pallidus internus (GPi) (Espinoza et al. 2010; Espinoza et al. Stereotact Funct Neurosurg 90(suppl 1):1-202, p 61, 2012). Definitive chosen target was decided after single-cell microelectrode recording, intraoperative test stimulation, thresholds for stimulation-induced adverse effects and best clinical response compared to baseline status. Fahn-Tolosa-Marin tremor rating scale (FTM-TRS) was used to evaluate outcome. The electrode was implanted in the nucleus with the best tremor suppression achievement; on the other hand, GPi DBS was initially decided if one of the following conditions was present: (a) If Vim nucleus anatomy was grossly altered; (b) when intraoperative tremor control was unsatisfactory despite Vim high-intensity stimulation; or (c) if unaffordable side effects or even tremor worsening occurred during intraoperative macrostimulation. Seven patients received definitive Gpi DBS implantation, while three patients received Vim DBS. In all observed cases, we observed an improvement on the TRS. In two cases where Vim thalamic anatomy was altered by the pathological insult GPI was planned from the beginning, and same was true in two additional cases where the Gpi nucleus showed major alterations allowing only Vim planning. Over all cases, the average improvement in tremor was of 2.55 points on the TRS or a 64 % increase in measured results; with a minimum of 1 point (25 %) improvement in one case and a maximum of 4 points (100 % improvement) also in one case. All the results were sustained at 2 years follow-up. One case with predominant resting component, implanted in the GPi, achieved the maximum possible tremor reduction (from 4 to 0 points, meaning 100 % tremor reduction); in the nine resting cases, the average reduction was of 3 points (or 75 %). DBS demonstrated in this case series adequate tremor control in 10 patients unresponsive to medical therapy. Presurgical planning of two targets allowed choosing best optimal response. Gpi stimulation could be considered as an alternative target for cases in which thalamic anatomy is considerably altered or Vim intraoperative stimulation does not produce satisfactory results. SN - 1437-2320 UR - https://www.unboundmedicine.com/medline/citation/25990341/Deep_brain_stimulation_of_the_globus_pallidus_internus_or_ventralis_intermedius_nucleus_of_thalamus_for_Holmes_tremor_ L2 - https://dx.doi.org/10.1007/s10143-015-0636-0 DB - PRIME DP - Unbound Medicine ER -