Factors involved in long-term efficacy of deep brain stimulation of the thalamus for essential tremor

Clinical article

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Object

Although nucleus ventralis intermedius stimulation has been shown to be safe and efficacious in the treatment of essential tremor, there is a subset of patients who eventually lose benefit from their stimulation. Proposed causes for this phenomenon include tolerance, disease progression, and suboptimal location. The goal of this study was to assess the factors that may lead to both stimulation failure, defined as loss of meaningful tremor relief, and less satisfactory outcomes, defined as leads requiring voltages > 3.6 V for effective tremor control.

Methods

The authors present their clinical outcomes from 31 leads in 27 patients who had effective tremor control for > 1 year following nucleus ventralis intermedius stimulation. All patients postoperatively had a mean decrease in both the writing and drawing subscales of the Fahn-Tolosa-Marin Tremor Rating Scale (p < 0.001).

Results

After a mean follow-up of 40 months, 22 patients continued to have tremor control with stimulation. Four patients eventually lost efficacy of their stimulation at a mean of 39 months. There was no difference in age, duration of disease, or disease severity between the groups. Examination of perioperative factors revealed that suboptimal anteroposterior positioning as evidenced on intraoperative fluoroscopy occurred significantly more frequently in patients with stimulation failure (p = 0.018). In patients with less satisfactory outcomes, no difference was seen between group demographics. Fluoroscopy again revealed suboptimal positioning more frequently in these patients (p = 0.005).

Conclusions

This study provides further evidence that suboptimal lead position in combination with disease progression or tolerance may result in less satisfactory long-term outcomes.

Abbreviations used in this paper: AC = anterior commissure; AP = anteroposterior; DBS = deep brain stimulation; PC = posterior commissure; TRS = tremor rating scale; VC = ventralis caudalis; VIM = nucleus ventralis intermedius; VOA = ventralis oralis anterior; VOP = ventralis oralis posterior.
Article Information

Contributor Notes

Address correspondence to: Roy A. E. Bakay, M.D., Rush University Medical Center, 1725 West Harrison Street, Suite 970, Chicago, Illinois 60612. email: Roy_Bakay@rush.edu.
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